Membership Plan C – Yearly

£230.00 / year

To facilitate the provision of information and newsletters to members all details given will be recorded on a database. This will not be used for any
other purpose withput your prior consent. Should you have any objection to such a record being maintained you are entitiled to request exclusion by
writing to the Club Secretary.

Title *

Forename *

Surname *

Date Of Birth *

Nationality *

Occupation *

N.I Number *

Tel (Home) *

Tel (Work)

Mobile *

E-mail *

Emergency Contact Name: *

Emergency Contact Tel No: *

Please provide details of any medical conditions you may wish us to be aware of. This information may prove useful if you are taken ill during a game or whilst at the Club Premises

Please provide any skills you possess which you are willing to share with the Executive Committee in order that you can be contacted to offer advise or assistance, should your particular field or specialiaty be required by the club.

I hereby apply for membership to BHRFC. I agree to observe and abide by the Club Rules now in force and hereafter amended. I understand that if I do not observe the Rugby Union Regulations I shall not be eligible to remain a member of the Club. I confirm that I have no outstanding obligations to any previous Rugby Club and that I am not currently subject to any disiplinary action. I enclose a Standing Order form to cover subscription fees for the season. *

Ethic Origin *

Asthma or Bronchitis *

Heart Condition *

Fits, Fainting or Blackouts *

Severe Headaches *

Diabetes *

Allergies to any known drugs or medication *

Any other allergies e.g. material, food, insect Bites etc. *

Other Illness or disability *

Any recent contact with contagious diseases or infection *

Have you received vaccination against TETANUS within the last five years? *

Are you receiving medical treatment of any kind from your doctor, or hospital? *

Have you been given specific medical advice to follow in emergencies? *

If the answer to any of the above questions is YES please give details here ( inc. dosage of any medicines or tablets):- *

Declaration. *

In the event of an accident or injury, I hereby give my consent to the administration of first aid by a qualified first aid official and / or being given medication as instructed. I agree to any emergency dental, medical or surgical treatment including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand the extent and limitations of the insurance cover provided.

SKU: mship-c-yr Category:

Description

To facilitate the provision of information and newsletters to members all details given will be recorded on a database. This will not be used for any
other purpose withput your prior consent. Should you have any objection to such a record being maintained you are entitiled to request exclusion by
writing to the Club Secretary.

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