East Essex Triathlon Club Membership Form 2012

*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 recommends that you sign up for membership England Athletics Affiliation, if you are not already affiliated with another club. This membership will allow you to compete with the club in the Winter Cross Country league and entitling you to a reduced entry fee in UKAA races like Southend 10K. If you do not choose this options, please remove £5 from your membership fee.
EETC members are sent a weekly email newsletter please tick this box if you do not wish to receive this email
Membership fee:	Adults: £31 Cross Country Only: £10 (includes affiliation to England Athletics) Age 18 – 21: £12 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: Paul Gammon	Signed: __________________________________
26 Galleydene Hadleigh, Benfleet
Essex SS7 2QA