Membership
Application
2011

First Name:

Surname:

Address: (inc. postcode)

Date Of Birth: (DD / MM / YYYY)
  /    /  

Male Female

Will Red Rose be your first claim club?
Yes No
(if no, please give name of your first claim club below)


E-Mail:

Phone No: (no spaces)


I agree to be contacted & receive club news by E-Mail.
I agree that my personal data may be kept on record by the club.
I agree to the disclosure of my personal data to Uka & England Athletics.
I confirm that I am an amateur as defined by English Athletics
and that the above data is correct.