Mount Hawke Youth Group
Member Registration
PERSONAL INFORMATION
FIRST NAME(S)
*
GENDER
MALE
FEMALE
SURNAME
*
DATE OF BIRTH
*
/
Day
/
Month
Year
Date
ADDRESS (1)
*
HOME TELEPHONE No.
ADDRESS (2)
*
MOBILE TELEPHONE No.
TOWN
*
EMAIL ADDRESS 1
COUNTY
*
EMAIL ADDRESS 2
POSTCODE
*
EMERGENCY CONTACT INFORMATION
CONTACT NAME
*
CONTACT EMAIL ADDRESS
DAYTIME TELEPHONE No.
*
MOBILE TELPHONE No.
MEDICAL HISTORY
HAVE YOU A HISTORY OR RECEIVE MEDICATION FOR ANY OF THE FOLLOWING:
TICK AS APPROPPRIATE
ASTHMA
DIABETES
EPILEPSY
PLEASE STATE ANY OTHER MEDICAL CONDITIONS OR ALLERGIES YOU HAVE
DECLARATION
I confirm that I have received and read a copy of the
Member Information and Terms and Conditions
and fully understand and agree to them.
*
I have read and agree to the Terms & Conditions
Date
*
/
Day
/
Month
Year
Date
FOR MEMBERS UNDER THE AGE OF 16
I am the Parent / Guardian of the member and I have received and read a copy of the
Member Information and Terms and Conditions
and fully understand and agree to them on the member"s behalf.
I have read and agree to the Terms & Conditions on the member"s behalf.
Date
/
Day
/
Month
Year
Date
NAME
Parent
Legal Guardian
Please enter address details if different from above
ADDRESS (3)
ADDRESS (4)
TOWN
POSTCODE
Mount Hawke Youth group - Registered Charity No. 1011411 -
www.mounthawkeskatepark.com
E-mail
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