East Essex Triathlon Club Membership Form 2010

*Name:		*Date of Birth:
*Address:		BTF No: (if applicable):
		*Home Phone:
		Mobile:
*Post Code:		Work Phone:
Occupation:		*Ethnic Origin:
Email Address:
Emergency Contact Name:		Emergency Contact No:
Estimated Swim Time (400meters)		__________ mins __________ seconds
I am Registered Disabled:	Yes / No	Medical Conditions:
Are you a member of another England Athletics affiliated club?			Yes / No
If yes, is East Essex Tri your first claim club for UK Athletics events?			Yes / No
East Essex Tri Club is affiliated to England Athletics, through your club membership we will register you with UKAA and pay your membership, entitling you to a reduced entry fee in UKAA races like Southend 10K. UKAA will send you membership form separately. If you are between the age of 18 and 21 and wish to be a member of UKAA please add £5 to your membership fees.
Membership fee:	Adults: £12.50 Cross Country Only: £5 Age 18 – 21: £6 Under 18s (Use Children’s form)

* - Mandatory fields

Cheques payable to "East Essex Triathlon Club" I understand that I am requesting full membership of the East Essex Triathlon Club. I understand that the club is committed to promoting the sport of Triathlon and part of this commitment includes the running of four or more events annually. I agree that I will participate in marshalling in at least one of these events.
Send to: Andrew Dawbarn	Signed: __________________________________
17 Ely Way, Rayleigh SS6 9TR