Rebel Runners ~ Medway. Membership Application Form

Title

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Date of Birth *(must be over 13 years old)*

Date

Sex at Birth*

MaleFemale

Emergency Contact Name*

Emergency Contact - Relationship to you*

Emergency Contact - Phone Number*

By signing this declaration either in person or digitally:

I confirm that the information I have given is true and complete.
I understand that any false information may result in my application being denied.
I confirm that I have read and accept the Rebel Runners ~ Medway Constitution (available on our website)
I agree to the disclosure of my personal data with England Athletics.
I accept that photography and filming may take place at any team events and may be used for promotional material.
I understand that the SPOND app shares some information with other users – you can choose what you share when joining.

I declare that I am over 13 years of age and fit to run. If I have never participated in this sport before I will seek medical advice and I understand that the club will be in no way responsible for death or injury caused during participation in events or training for this club.

Age 13–15 year-olds must have a parent/guardian that is a member at the club.

13-14 years must be accompanied by a member acting with the responsibilities of a parent/guardian, (they must run with them – at the same pace).

15-year-olds can run unaccompanied with the agreement from the duty Run Leader (LiRF) in advance and with the consent of the parent/guardian. Please ask for details.

16–17-year-olds can run unaccompanied.

Please notify us of any condition, medical or otherwise, or disability that you feel we should know about and/or where you may need extra support with a session. We will share this with our coaches on a need to know basis.

Signature

If I am under the age of 18 thesignature on this form will be that of my parent/guardian.

Date*

As a member I am aware that my data is being passed to the Athletics Governing Bodies and will be processed in accordance with their privacy statement.*

Yes

As a member I am aware of and agree to be bound by the UKA Anti-Doping Rules and have agreed to sign up to the Senior Athletes Code of Conduct.*

Yes

Membership Choice

Membership fees for new joiners include a one off £5 admin fee (standard membership for renewing members is £35).

For memberships with EA Affiliation, we pass £20 to EA.

For Juniors, EA affiliation is optional from age 15.

Second claim is where you are first claim with another EA affiliated club.

Options*

STANDARD "FIRST CLAIM" MEMBERSHIP with EA Affiliation £40STUDENTS & OVER 60'S with EA Affiliation £32.50JUNIORS 13-17 Years without EA Affiliation £12.50JUNIORS 15-17 Years with EA Affiliation £32.50SECOND CLAIM £20.00

Membership Bundle

If you would like to take advantage of our membership bundle and receive a reduced price top, please select one of the options below (or select n/a).

Please include further information (colour, size etc.) in the box below or you can email this to treasurer-rebelrunners@outlook.com at a later date if you are still deciding.

Please note that our First Claim Kit (which must be worn at UKA races & Club Championship Events if entering under the club's name) is Black with Green writing.

See top options on our website : www.rebelrunnersmedway.co.uk/shop/

Options*

N/AAdd a black or green t shirt to your membership (additional £16)Add a black of green vest to your membership (additional £13)

The total amount I am paying for my membership is £blanks.

Top details. Please include: Men's/Women's top, colour (reminder that black tops must be worn in UKA registered races), size , name/nickname you would like on the back. (sizing information is available through the shop section of our website)

Rebel Runners Bank Details:

Sort Code 60-08-36 Account Number 64612651

(please make a note of these details if you are paying after filling this form in)

When you become a member of or renew your membership with Rebel Runners ~ Medway you will automatically be registered as a member of England Athletics. We will provide England Athletics with your personal data which they will use to enable access to an online portal for you (called myAthletics). England Athletics will contact you to invite you to sign into and update your MyAthletics portal (which, amongst other things, allows you to set and amend your privacy settings). If you have any questions about the continuing privacy of your personal data when it is shared with England Athletics, please contact dataprotection@englandathletics.org.”