ࡱ> ILH7  bjbjUU 2F7|7|l> >: ($D d== ΅\> ==| 0:== &SOUTHPORT WATERLOO ATHLETIC CLUB(Affiliated to North of England AA and UK Athletics)Membership Application INCLUDEPICTURE \d "C:\\My Documents\\Athletics\\Swac\\Web\\aboutus\\pdficon.gif" \* MERGEFORMATINET  HYPERLINK "applnform.PDF" printer friendly versionWhat is your name and address? First Name(s)TitleLast NameGender M/FAddress Line 1Date of BirthAddress Line 2Ethnic OriginTownDisabilityCountyPost CodeCurrent SchoolHow can we contact you? Home TelephoneMobile PhoneWork TelephoneFaxE-mailAre you a member of another athletic club? (Yes / No) Name of any previous clubStatus ie first or second claimDate of resign from prev clubWhat kind of events do you expect to participate in? (P) Cross CountryFell & HillRace WalkingRoad RunningTrack & FieldAre you an athletics volunteer? (P) TimekeeperTrack JudgeField JudgeStarterMarksmanAncillaryCoach Qualification LevelEvent(s)I wish to become a first claim member of Southport Waterloo AC. I confirm that I am eligible to compete under UK Athletics rules. I *agree / * do not agree to the use of photographs including me being used on the Club's web site or in material promoting the club. I *accept / *do not accept that my personal data will be held by the club on a computer. I *agree / *do not agree to the disclosure of my personal data in a list of members and to the North of England AA. *Delete as applicable. Signed . Dated Parent / Guardian (if applicant is under 18) General Secretary: Ron Scott 23 Stanley Ave Southport Merseyside PR8 4RU 01704 566995Annual subscriptions: (Please send or hand in with this form.) Under 174 + 1*17 185 + 1*19 & over8 + 1** North of England AA registration fee for athletes aged 11 and over.Membership Secretary: Susan Cooper 15 York Close Formby Merseyside L37 7HZ 01704 871898Ver 2.201/03FOR OFFICIAL USE:Proposer Seconder . Date of election .. Secretary subs paid .........m/card issued .................. 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