Membership Application

Name

Address

Postcode

Gender

Date of birth

Tel (Home)

Mobile

Email Address

Emergency Contact

Emergency Tel (Home)

Emergency Tel (Mobile)

Other Clubs Other Clubs KCC will be your first claim (main) club I am a member of another cycling club My existing club will be my first claim (main club)

Details of other clubs you are a member of

Disability and Medical Information Disability and Medical Information I have a disablity that I feel the club should be aware of I have a medical condition that I feel the club should be aware of I have recommended treatment or actions in connection to my disability or medical condition that the club should be aware of I do not have any that the club should be aware of

Brief detials

Your Membership Your Membership SENIOR £15. Over 18 years of age on the 1st January. JUNIOR FREE. Under 18 years on the 1st January. If under 16 complete the Parental Consent Form FAMILY £20. Up to 2 adults and 2 children.

Declaration (You must tick ALL) Declaration (You must tick ALL) I declare that the above to be correct and that I am an amateur as defined by the rules of British Cycling and Cycling Time Trials organisations. If my medical circumstances should change in the future I will notify the club officials of any condition or disability that they need to be aware of. I understand that I will from time to time be expected to provide help at club events I am happy to recieve KCC newsletters and other updates via emai