Membership Form

Personal

First Name *

Last Name *

Gender *

Email Address *

Contact number *

Date of Birth *

Parent/Guardian Name *

Parent/Guardian Contact Number *

This applicants relationship to you *

Address Line 1 *

Address Line 2

Address Line 3

Town / City *

Postcode *

Can you / the applicant swim 50 Meters Unaided?

Medical

Applicant Health Conditions? *

It is important that West Yorkshire Canoe Club Organisers & Coaches should know whether you / this applicant suffer from any illnesses or medical conditions. Please check the box if you have any medical conditions other matters which we should be aware of.

For example (but not limited to):
Allergies, Asthma, Epilepsy, Diabetes , Skin conditions , Recurring Headaches
Anything you feel is relevant not listed above

Please provide details of any health / medical conditions *

Please use the space above to state in confidence any health or other matters which we should be aware of.

For example (but not limited to):
Allergies, Asthma, Epilepsy, Diabetes , Skin conditions , Recurring Headaches
Anything you feel is relevant not listed above

Doctors / GP Clinic Name *

Doctor / GP Clinic Telephone *

Does the applicant experience any medical conditions requiring medical treatment and/or medicine?

Please give details such as method (Injection, inhaler, etc), Dosage and Frequency

Do you consider yourself to have a health issue, long term illness, disability or impairment that limits your daily activity?

Please provide details of your condition or support requirements. *

Emergency Medical Treatment *

Emergency Medical Treatment Exclusions *

Additional Information

Please provide any other information West Yorkshire Canoe Club should know which could affect our ability to work with you / the applicant effectively.

Emergency Contact

Emergency Contact Name *

Emergency Contact Telephone Number *

Emergency Contact's relationship to applicant *

Paddle UK Membership

Paddle UK Membership Number

Paddle UK, Formally British Canoeing

Terms & Consent

Media Consent

I consent that photographs or video taken by authorised personnel may be taken at British Canoeing or West Yorkshire Canoe Club events may be used to promote paddlesport and improve performance.

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Payment

Individual Membership £25.00

12 months membership. You'll be taken to our secure payment provider to complete your payment.