Stewartry Wheelers Membership Application Form 2005

This is an application for membership to the Stewartry Wheelers for the period January 2005 to December 2005, the cost of membership is the same regardless of when the application is made. Please print out this form, complete it, and return it to the address at the bottom.

Rates

Personal Details
Full Name:
Date of birth
Sex: M/ F:
Address:
Postcode:
Telephone:
Email:
Type of membership (tick one)
Individual   Family   Junior  
Please enclose correct payment - cheques made payable to 'Stewartry Wheelers'
About you:
Clothing - Although not mandatory, distinctive Stewartry Wheelers clothing will be available to purchase, we would encourage your support of the club by purchasing the club wear. To aid us in ordering stock, please detail your sizes below and if possible, indicate the clothing you might be interested in
Height   Chest   Waist  
Please tick the box each type of clothing you will be interested in - prices will be sent separately
S/S Jersey   L/S Jersey   Shorts  
Tights   Cap   Gillet  
Skin suit   Jacket  
Your cycling interests:
Stewartry Wheelers is run by cyclists, for cyclists, to cater for your needs it is important we know what type of cycling you want, please tick your interests below
Audax   Just riding   Mountain Bike  
Road Racing   Social Rides   Time Trialing  
Touring  
Your safety:
You will be participating in a physical activity, every effort will be made to ensure your safety but we will need to know if you are allergic to any medication or suffer an illness that may affect you whilst out with the club, if so, please detail below, this section is NOT compulsory, cannot be used without your consent and will be held in strict confidence.
Emergency contact:
In the event of an emergency, please detail the name and number of an emergency contact
Name
Contact number

Parental/Guardian Consent

(to be completed if any applicants are less than 18 years old)

I (name) being the parent/guardian of the above mentioned applicant:

• Understand and agree that my son/daughter is able to participate in events organised by the Club and does so entirely at his/her own risk. I am satisfied that my son/daughter is sufficiently responsible and competent to assume full and entire responsibility for his/her own safety whilst engaged in any event promoted or organised by the Club.

• Confirm that my son/daughter does not have any disability or medical condition, physical or mental, that has not been disclosed above that could affect his/her ability to ride safely.

Signed (Parent) Date:

Declaration (to be signed by all applicants over 18 years)

I confirm that I have completed the above information as accurately as possible and agree this information may be held by the Stewartry Wheelers.

Signed Date

Name

Please return completed forms with payment (Cheques payable to 'Stewarty Wheelers') to Andrew Crooks, 'Balcraig' , 63 Rotchel Road, Dumfries, DG2 7SA or Castle Douglas Cycles, 11 Church Street, Castle Douglas, DG7, 1 EA. If you are paying by cash, do not post money to Andrew Crooks but present to Castle Douglas Cycles. Stewartry Wheelers does not take any responsibility for cash that is lost when posted.