Membership Application

Your Membership (select before completing for the form) Your Membership (select before completing for the form) 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.

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