Membership Application

Your Membership (select before completing for the form) Your Membership (select before completing for the form) Standard. (Individuals) Family. Up to 4 people living in the same home Junior. Under 18 years on the 1st January. If under 16 complete the Parental Consent Form

Name

Address

Postcode

Tel (Home)

Mobile

Email Address

Date of birth

Gender is optional, you need to declare if you wish to participate in competitions and our club league awards/trophies.

Emergency Contact

Emergency Tel (Home)

Emergency Tel (Mobile)

Other Clubs Other Clubs KCC will be my 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 details

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