Adult Membership Application Form

1. Name *

1. Name

First Name

Last Name

2. Email Address *

3. Address *

3. Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

4. Landline

5. Mobile *

6. Date of Birth *

6. Date of Birth

YYYY

7. Gender *

Female

Male

Prefer not to Say

8. Ethnicity

9. Religious Beliefs

10. Do you have a disability (i.e. a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities)? *

If yes, will you need any reasonable adaptations to be made to enable you to participate? Please mention them here or contact the Welfare Officer (details below)

11. Any relevant medical information, including long term illnesses, medication taken and injury problems. Please list any need for inhalers, epi-pens etc and circumstances/reasons for use.

12. Any relevant allergy information

13. Any specific dietary needs (i.e. vegetarian)?

14. Name, address and telephone number of your Doctor

Emergency Contact Details

15. Relationship *

16. Name *

16. Name

First Name

Last Name

17. Landline

18. Mobile *

19. Email *

20. Address *

20. Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Rowing Activity

All members of the club must be able to swim 100m in light clothing and to participate in swim tests and capsize drills as required by the Water Safety Officer.

21. I confirm that I can swim 100m in light clothing and I acknowledge that I will be asked to complete a capsize drill *

22. In the past 4 weeks, on how many days have you done 30 minutes of sport and/or recreational physical activity? Do not count any curriculum activities at school/college. Do not include cycling or walking unless it was for sport or recreation. Gardening, DIY and housework should not be included. Please write the number of days between 0-28: *

23. Current level of Rowing/Coxing experience and previous club(s): *

24. I would like to be a: *

25. I am applying as a: *

Permissions

27. There may be video or photography at some sessions which may be used for coaching and/or publicity materials (posters/website) for Cambridge '99 Rowing Club or Sportivate. Images will not be accompanied by names or other details to identify individuals. I grant permission to be filmed or photographed during the sessions as described above. *

Yes

28. We work closely with the rowing national governing body, British Rowing. As part of your membership, you must be registered with British Rowing. I grant permission for Cambridge '99 RC to pass on my details to British Rowing *

Yes

29. Consultants working for Sport England to monitor Sportivate may want to send you a survey.

Please select if you DO NOT want to be sent the survey by email

Please select if you DO NOT want to be sent the survey link by text to your mobile

30. County Sports Partnerships may wish to notify you about other sports activities.

Please select if you DO NOT want to be notified

31. British Rowing occasionally passes on email addresses of its members to provide data for sport or market research.

Please select if you do not mind being contacted

32. British Rowing produces a rowing orientated email newsletter.

Please select if you want to be sent this newsletter

All applications must be accompanied by the relevant joining fee and annual subscription, to be paid monthly by standing order. Please pay your joining fee and set up your standing order to:

Cambridge '99 Rowing Club Barclays Chesterton, Cambridge Sort Code: 20-17-35 Account No: 10228605

33. Please confirm you have paid the joining fee and set up your standing order

I confirm I have paid all relevant fees and set up my standing order

If it is considered by the committee that the granting of membership would be detrimental to the aims and objectives of the club, the committee are entitled to refuse membership and will provide full reasons for doing so.

By signing my name on this form, I apply to join the Cambridge '99 Rowing Club and agree to abide by the rules and regulations of the club (see rules of conduct on Join Nines page) and its national governing body, British Rowing. I have completed the medical details above and I consent that, in the event of any illness/accident, any necessary treatment can be administered to me/my child, which may include use of anaesthetics.

Signature/Name

(Should be signed by parent/guardian if applying for junior membership)

Date

YYYY

All applications must be completed for Health and Safety reasons. All information contained within will be held in the strictest of confidence, and is held in accordance with the Data Protection Act.

Please ensure that the Membership Secretary is informed of any change to this information as soon as possible. Any queries or problems please email membership@cambridge99.org, captains@cambridge99.org or welfare@cambridge99.org