Membership Form Ryecroft Judo Club

Ryecroft Judo Club,

West End,

Beeston,

Nottingham. NG9 1GL.

www.ryecroftjudoclub.co.uk

Personal Details:

Surname First Names

Date Of Birth (DD/MM/YYYY) Gender (Please tick) Male Female

Grade BJA Licence No

Tel Number E mail Address

Current Address: Home Address (If different):

Street Street

Town Town

City City

Postcode Postcode

Emergency Contact Details 1: Emergency Contact Details 2:

Name of Contact Name of Contact

Relationship Relationship

Telephone (Daytime) Telephone (Daytime)

(Evening) (Evening)

(Mobile) (Mobile)

Address Address

Medical Conditions/Allergies : (It is VERY important that you make RJC aware of anything which may affect you whilst on the judo mat).

I understand that it is my responsibility to hold a valid BJA judo license. I have read, understood and agree to the rules outlined

in the Code of Practice and Constitution and Child Protection Policy (copies of which were made available to me and can be

found on the website). All details will be held in accordance with the terms of the Data Protection Act 1998.

By signing this form you agree to all the details outlined above.

Signature (Parent/Carer): Date:

(Parent if under 16)

Membership Fee Paid: £ Renewal Date: Signed Committee Member: