ATHLETE MEMBERSHIP FORM

STANDISH GLOBE RUNNERS
PLEASE COMPLETE ALL DETAILS
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of birth*

DayMonthYear
Date
CURRENT LEVEL OF RUNNING
CURRENT LEVEL OF RUNNING (eg NEW STARTER, UPTO 5K, 5K 10K, 10K+)*
EMERGENCY CONTACTS
Please detail below any disability you have and/or any additional support you may require from our club volunteers
PARENT / CARER DETAILS

If you are under 18 years of age, please ask your parent or guardian to complete the following section.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
PHOTOGRAPHY AND VIDEO CONSENT

Standish Globe Runners recognises the need to ensure the welfare and safety of everyone in athletics.

By signing, you (or parent/guardian for runners under 18) consent to Standish Globe Runners photographing or filming my involvement in athletics from the date shown on this form for the purposes of publicising and promoting the club or sport, or as a coaching aid.

Also, in accordance with the child protection policy and procedures, we will not permit photographs, video or other images of children/young people to be taken without the consent of the parent/guardian and child/young person.

Standish Globe Runners will take all possible steps to ensure these images are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately you should inform the club immediately.

If you do not wish for your image to be used as stated please let one of the run leaders know.
CLUB PRIVACY STATEMENT & COMMUNICATION PREFERENCES

Standish Globe Runners take the protection of the data that we hold about you as a member very seriously and will do everything possible to ensure that data is collected, stored, processed, maintained, cleansed and retained in accordance with current and future UK data protection legislation.
Health declaration

In preparation for physical activity, please tell us about ALL of your existing medical and physical conditions. It is your responsibility to complete this form before participating in any physical activity. For any conditions that can be affected by exercise, you may be asked to consult your doctor. The information contained will be treated as confidential and only revealed to relevant team players (staff) for your safety.Please note that it is your responsibility to inform us of any changes in your medical or physical condition.
Do you have, or have you had any of the following conditions? Please tick any that apply.

ArthritisHeart problems/diseaseAsthmaHigh cholesterolDiabetesStrokeEpilepsyFamily history of heart disease or strokeOsteoporosisHigh blood pressureLow blood pressureDizzinessChest painOther
For other, please provide brief details.
Do you have, or have you had, any joint problems, pains or injury in any of the following regions? Please tick any that apply.

Ankles/feetShouldersKneesNeckHips/pelvisElbowsLower backWristsMuscular painOther
For other, please provide brief details
Are you currently taking any medication?
If yes, please describe.
Are you, or have you been pregnant in last 12 months?
If yes, how many months and any related conditions?
Are you currently exercising?
If Yes, what type and how many times a week
How hard (choose 1 option)
If No, have you in the past and what type?
I understand that I may participate in physical activities which may expose me to certain risks and that I do so at my own risk. I will not hold Standish Globe Runners liable for any injury, loss, damage or death caused to me or my property whether by negligence, omission, and breach of contract or in any way whatsoever.
I undertake to complete a new health questionnaire in the event of any change in my medical status. I understand that it is my responsibility to advise the run leaders of any medical/physical conditions that may prevent me from exercising, and that I participate in exercise at my own risk.
By completing this form, I confirm that:
- I have read and understood the privacy statement as well as how data and images will be used and shared
- I am willing to abide by the club's code of conduct for athletes
- I will advise the club of any changes to my health
- I will report any injuries or accidents immediately to a run leader
PRINT NAME*
DATE*

DayMonthYear
Date
We look forward to welcoming you and your family to the club in the near future. To find out all the latest club information, please visit our Facebook page.
ATHLETE DETAILS
Should be Empty:

STANDISH GLOBE RUNNERS

CURRENT LEVEL OF RUNNING

EMERGENCY CONTACTS

PARENT / CARER DETAILS

Health declaration

ATHLETE DETAILS