Registration Form

Personal Details = required

Full Name

Home Address

Home Phone

Mobile Phone

Email Address

Alternate Email

Date of Birth

Gender

Male Female

Occupation

(Please indicate if you would be willing to help the club should it need your expertise.)

Membership Start

When would you like your membership to start?

As Soon As Possible Specific Date

Preferred Start Date
(if applicable)

Membership Category

Please select your preferred membership category

	Category	Cost
	Beginner This is a guest membership and should be chosen by anyone wanting to join our beginners courses Only available to new applicants aged 18 or over.	£0.00
	Base Adult Membership Only available to people between the ages of 18 and 69 inclusive.	£16.00
	Affiliated Adult Member Only available to people between the ages of 18 and 69 inclusive.	£32.00
	Veteran Member Only available to people aged 70 or over.	£0.00

Data Protection

I understand that any personal data I provide on this site will be processed in accordance with the Terms & Conditions and Privacy Policy. I have read and agree to the Terms & Conditions (https://www.rugeleyrunners.co.uk/Home/TermsAndConditions) and the Privacy Policy (https://www.rugeleyrunners.co.uk/PrivacyPolicy;).

Signature

Date

Please return completed forms to: Ian Doody, 32 Thompson Road, Rugeley, Staffs, WS15 1HW, UK

Use this form to send an email to another member. You may only send to one member at a time. Your registered email address will be passed on to this member but you may also include alternative contact details.

Note: Emails sent via the website are not entirely private. A copy of every email is held on the database and this can be accessed by the club officers using the Sent Emails page.

From

Alternative contact email

Another email address which the recipient can use to contact you.

Alternative contact details

Other contact details which the recipient can use to contact you e.g. phone number.

Subject

Message

Copy this message to my email address

Title

Description

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