Membership Form

First Name
Last Name
Street
City
County
Country
Post Code
Parent's Name (if participant is under 16)
Parents First Name:
Parents Last Name:
Parents Contact Telephone Number:
Email
1V Groups:
Do you (or your child) have any long term illnesses, health problems or disability that limits their activities? If yes, please use the space below to record the information:
Authorisations - I authorise the following person to collect my child from the session if I am not available *Applicable for children under 16 Authorising First Name:
Authorising Last Name:
Emergency Contact Name:
Emergency Contact Mobile:
Emergency Contact Relation:
Photo Consent: