Player Membership

Name: Player Membership
SKU: player-mship
Price: 23.00 GBP
Availability: InStock

£23.00 / month

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

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. *

I Agree

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.