I apply to join ELY RUNNERS (tick appropriate box below)

                  1st Claim           OR         2nd Claim

Surname:     

First Name:  

Date of Birth (dd/mm/yyyy)   e.g. 07/11/1975

Phone Numbers:   Home   

                                    Work    

                                 Mobile

Email Address:    Main  

                        Secondary (if applicable)
 

                                                    Other Info:
    In the box below please include:-

a) Any Personal bests including distance, time,  place and date achieved
b) Brief details of any coaching, officiating and other athletic
     administrative qualifications and experience.
c) If you do not wish your photograph and/or name to appear on the
    club web site please state the extent to which you wish to remain anonymous.
    (Ely Runners will never publish your date of birth, home address,
     phone number(s) or email address without your explicit permission.)
d) Any relevant medical conditions

Please tick the box below to confirm you have
checked the  above details and that they are correct.
Unless notified to the contrary within 28 days, 
this application is deemed accepted by the Committee.
Membership will be valid after confirmation of  payment has been received.
Membership enquiries to Rod Baron membership@elyrunners.co.uk

Yes, I confirm my details   (Use the "Submit" button below to send your form)