ࡱ> '` bjbjLULU {p.?.? ||||$dKk     S S S K*M*M*M*O* J j$7lhnjg#1 "S g#g#j||  %k%%%g#|8  K*%g#K*%%%  #4%&k0Kk%!o#!o%!o%S h%M!T!S S S jj%S S S Kkg#g#g#g#|||||| Woodford Rugby Football Club Membership Application Form - Season 2011-2012 Please correct any pre-printed details as necessary, and please complete all the non-shaded boxes below. Main Members Personal Details Title SurnameForenamesAddressPost CodeHome PhoneMobile / Work PhoneEmail Date of BirthOccupation (Adult)School (Child) Membership (all ages as at 1st Sept 2010)Subscription (please circle as appropriate)Senior Player (over 19, see below for student / unemployed concession) (excludes Match Fees)115Senior Player who is a full time student (over 19) or unemployed (excludes Match Fees)70Mini / Youth / Colt1052 Mini / Youth / Colt players140Mini / Youth / Colt (whose parent(s) is (are) member(s)40Family Membership (voting rights & privileges equivalent to 2 adult members) * Only players under the age of 21 may be included unless in full time education170Remote Full-time University Student - playing very occasionally (excludes Match Fees)20Social Member105Partners of Senior Player or Social Members please complete below20OAP or Country Member (living 70+ miles away)70Partners of OAPs or Country members please complete below10 Additional Family Members (continue overleaf if necessary)SurnameForenamesM/FDate of BirthEmail address (IMPORTANT !) Mobile  / /  / /  / /  / /  Parent or Guardian of Mini or Youth Players (detailed above):Any medical conditions or allergies (particularly please specify if allergic to penicillin):Alternative Emergency Contact Name and Tel. No.:I would like my child to take part in the mini/youth rugby training sessions and matches organised by Woodford Rugby Football Club. I understand that the Club its servants agents or employees are not under any liability whatsoever for loss of property, accidents or injuries of or to my child however caused during the course of training, preparation or matches played at Woodford RFC or other club grounds. I do however understand that every reasonable care will be taken to ensure my childs safety. Should the need arise and in my absence I agree to the person in charge at the time giving consent on my behalf for an anaesthetic or any other urgent medical treatment to be administered including but not limited to blood transfusions or invasive surgery. I have no objection to this membership record being held on computer files.Data Protection Act. The information you supply us with will be treated by Woodford Rugby Club in the strictest confidence in accordance with the Data Protection Act 1998 and will not be passed on to any third-parties. From time to time we may contact you with further details of Club policy or information. By giving us your email address you are agreeing to receive communications and information from us. We will not pass your personal details to anyone without your consent. If you prefer us not to contact you by email tick here Signature (of Senior member, parent or guardian) : ......................................... Please return completed form with appropriate remittance to: Mike Page, 42A Roebuck Lane, Buckhurst Hill, Essex, IG9 5QX. Please email any queries to mikepage@btinternet.com or call 07725 656435. Upon receipt of your Membership Fees a Fixture Card will be sent to you and Membership Card reactivated or issued (for new members) The Membership Card entitles you to a discount on goods purchased from the Bar. 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