Raging Dragons Membership Form

Raging Dragons Club Induction Registration

Complete the form below to register.
Contact Details
Name*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
E-mail*
Emergency Contact Details

Person(s) who should be contacted in the event of an emergency. Please provide contact details.
Emergency Contact Name

First NameLast Name
Emergency Contact Number

Area CodePhone Number

Additional Personal Details
Date of Birth:

DayMonthYear
Height (cm)
Weight (kg)
Can you swim 50m unaided? (If in doubt, please select No)*

YesNo
Do you have any previous water sport experience?

Yes (please list in the box below)No
Previous Watersport Experience
Please use this space to provide any relevant information about previous watersport experience.
Medical/Other Qualifications
Do you have a first aid/other qualifications, e.g. DBS checked? If so, please provide details.
Where did you hear about us?

A Friend or ColleagueGoogleBlog PostNews ArticleOther

Medical Details
Medical History*

I do not suffer from any condition that may affect my participation in the Club.I do suffer from a condition that may affect my participation. Please list in the box below.
Medical Details
Please use this space to provide any relevant medical information.
Payment Details
The easiest way and most efficient way to pay your £10 induction fee is by BACS.

Please send the payment to:

Account Name: Raging Dragons

Account Number: 63986624

Sort Code: 40-06-30

Reference: Your Name must be stated as a reference to faciliate us allocating your payment correctly

Note that the £10 would be deducted from your annual £140 membership fee if you subsequently decide to join.

Declaration
- I am confident in and around water
- I am aware that participation in watersports may involve strenuous activity and I am fit enouh to take part.
- I agree to qualified members of the Club giving me first aid treatment in an emergency.
- I agree that if photographs or video is taken of me while at the Club, it may be used for promotional and/or instructional purposes.
- I will notify the Club coaches of any change to the information given on this form.
Agreement*

I have read, understood, and accepted the rules.I confirm that the information on this form is correct and agree to the declaration above.
Signed*

Clear
Date*

DayMonthYear

Once you submit your application and payment, we will contact you to confirm registration. Thank you!
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Raging Dragons Club Induction Registration