Cubs Class - Application Form 2024-2025
Please read the 'CODE of CONDUCT' before completing this form.
Participant Details
Forename (s)
*
Surname
*
Date of Birth
*
/
Day
/
Month
Year
Date
Age (years)
*
Address (Line 1)
*
Address (Line 2)
*
Post Code
*
What ethnic background/origin do you class yourself as (optional)
*
Asian
Arab
Black
White
Other
Emai Address
*
Contact Number
*
Emergency Contact
Name
*
Relationship
*
Contact Number
*
Exercise Readiness Questionnaire
Have you ever been advised by your GP/Doctor, not to undertake exercise?
*
NO
YES
Do you have a bone or joint problem that could worsen by undertaking exercise?
*
NO
YES
Have you ever been advised by your GP/Doctor, not to undertake exercise?
*
NO
YES
Do you suffer from spells of dizziness or feeling feint?
*
NO
YES
Do you ever get chest pains, caused by exercise or high intensity tasks (i.e. cleaning) ?
*
NO
YES
Have you ever had high blood pressure?
*
NO
YES
Are you currently taking any medication?
*
NO
YES
Are you pregnant, or have had a baby in the last 6 months?
*
NO
YES
Is there any other information, reason or cause which may affect you whilst exercising?
*
NO
YES
Any other information (Include medication, injuries, surgery etc - please write CLEARLY)
COVID Vaccine:
*
YES - 1st Jab
YES - 2nd Jab
NO
Exempt
CLUB MEDIA: I would like to be included in media for club promotional purposes - including, but not limited to photography, video, audio or print. I understand that from time to time the club will give the rights and any media to third parties for editorial and broadcasting purposes (this applies to all media).
*
YES
NO
DECLARATION - Participant
*
DECLARATION - Parent/Guardian (for members under 18 years of Age)
DATE:
*
/
Day
/
Month
Year
Date
Submit
Should be Empty: