New Member with EA | Shropshire Shufflers

Shropshire Shufflers

An Inclusive Running Club

Membership Application (including EA)

First name

Last name

Address Line 2

Physical Activity Readinss Questionaire

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

When you do any physical activity do you feel any pain in your chest?

Do you ever have any chest pain when not doing physical exercise?

Have you ever felt faint or had spells of dizziness?

Phone Number

Address Line 1

Postcode

DOB - dd/mm/yyyy

contd.....

Do you have any joint or bone problems that could be made worse by any change in your physical activity?

Have you ever suffered from high blood pressure?

Are you currently on any medication that could affect your health by a change in your physical activity?

Are you pregnant or have you had a baby in the last 6 months?

Are you over 69 years of age?

Address Town

Sex at Birth

Male

Female

Please provide your In Case of Emergency (ICE) Contact Name*

Please provide your ICE Contact Number - ideally a mobile number*

We would like to send you "The Shufflette" our regular e-newsletter (approximately monthly) - giving Shropshire Shuffler news, including details about training nights, alternative runs and other club activities.

I would like to receive these emails

Yes

Club Championships - In order to take part in this fun intraclub competition we require your permission to share the run time data that you supply or that we can access from publicly available websites (e.g. parkrun results).

I would like to take part in the Club Championships

Yes

Terms and Conditions

By completing this form and joining Shropshire Shufflers you are agreeing to the following:

1. You have read and agree to abide by the Shropshire Shufflers Code of Conduct.

2. You will not hold any Club Coach or the Club liable for any loss, injury, illness or damage that may occur from your membership and you declare that you are an amateur as defined by UK Atletics rules.

3. The personal data you submit can be used by the Shropshire Shufflers for legitimate interests to administer your club membership, club competitions, communicate club notifications or be used by the Shropshire Shufflers for any other club legimate interests deemed appropriate by the Shropshire Shufflers Club Committee.

4. To share your basic details (name, address, email and DOB) with EA (England Athletics) for the purposes of processing your EA licence. Please contact dataprotection@englandathletics.org if you have any questions about the continuing privacy of your personal data when shared with EA.

5. Not to wear any headphones during any club arranged training activities.

6. To always wear either light coloured or reflective clothing during winter months (to be safe and be seen).

If you have ticked any of these options then please speak with you Doctor before participating in any new physical activity. This list of questions is not exhaustive and if you are in any doubt please speak to your Doctor first.

I have ticked an option and will check

None of the options apply

I agree to the terms and conditions and agree to pay £44