Name: _______________________________

Address: _____________________________

_____________________________________

_____________________________________

_____________________________________

Post Code: ___________________________

Tel No: _______________________________

Date of Birth: _____/______/______

Renewal

or

New member

First Claim

or

Second Claim

Fees (tick one)

In paid employment - First Claim

Not in paid employment - First Claim

Junior membership

Type of member (tick which applies)

Please accept my application/renewal for membership of Clowne Road Runners

I agree / disagree to have my contact details passed on to other Clowne Road Runners members.
(delete as required).

Must be signed by parent/guardian for under 18s

Signed: _____________________________________

Please send form and membership fee to:

Mr D Learad

The Gables

6A Doles Lane

Whitwell

WORKSOP

S80 4SW

Telephone: 01909 723818

E-mail: membership@clowneroadrunners.co.uk

CLOWNE ROAD RUNNERS CLUB

MEMBERSHIP APPLICATION FORM

Male

Female

Membership Number: _______________________________________________

Previous Club, if any: _______________________________________________

Resignation Date: _____/_____/_______

State First Claim Club: ______________________________________________

£10.00

Date: ______/______/_______

Club meetings held first Friday

Clowne Community Centre at

in every month.

7.30 pm.

Mobile: ____________________________________

E-mail: ____________________________________

Cheques made payable to "Clowne Road Runners"

Disciplines in which you intend to take part

(please tick)

MUST BE SUPPLIED

Ethnic Origin: _____________________________

Cross

Country

Fell &

Hill

Race

Walking

Road

Running

Track &

Field

In paid employment - Second Claim

Not in paid employment - Second Claim

Active runner

or Non-active runner

Life member

£6.00

£6.00

£5.00

£0.50