Membership Application Form
· To ensure that we have the correct details for Players, please insert the information requested below and return this form to:
D Skilbeck, 26 Dale View, Cockermouth, CA13 9EN
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Name: |
DOB |
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Address
Postcode |
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Telephone Nos Home Work Mobile |
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Email address |
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Ethnicity White ð Black or other ethnic minority ð |
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Membership Type (please attach cheque/p.o.
payable to Cockermouth Cricket Club)
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Payment Received ð …………………….(Membership Secretary) |
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DisabilityThe Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’. Do you consider yourself to have a disability? Yes ð No ð If yes, what is the nature of your disability? |
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Medical information (optional) Please detail below any important medical information that our Coaches and Senior Club Captains must be aware of (e.g. epilepsy, asthma diabetes, etc)
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Emergency contact details Please indicate the person(s) who should be contacted in case of an incident/accident: |
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Contact name |
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Emergency contact number |
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Additional Family Members included in Family Membership |
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Name |
Contact Phone number (if different to above) |
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* Junior members must also complete junior membership form