Club membership form

 

Leeds Mercury Cycling Club

 

We are pleased to welcome you to our club. To ensure that we have the correct contact details for you, please insert the information requested below and return this form to:

 

 Alistair Cameron, Treasurer, 29 Knox Street, Rodley, Leeds, LS13 1LZ with the appropriate payment, cheques made payable to Leeds Mercury CC, thanks

Membership required

 

ü

Juvenile/Junior (under 18)

£3.50

 

Senior (18 or over)

£10.00

 

Family (2 snr. + all jnrs at same address)

£14.00

 

Second claim

(jnr. £3, snr. £6, family £10)

 

 If you are under 16 please also ask a parent or carer to sign this form before it is returned. We will also use this information to ensure that you are kept informed about club events.

Personal Details of Individual

Name:                                                   Gender: Male     □                    Female □

Address:

 

Postcode:

 

Date of Birth:                                         Email:

 

Telephone Home:                                               Mobile:

 

Disability Information

The 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 □                          No □

If yes, what is the nature of your disability?

Visual Impairment □                 Hearing Impairment □               Physical Disability □

Learning Disability □                 Multiple Disability □

 

Other (please specify):

Cycling Information

Have you taken part in much cycling before? Yes □ No □

If yes, where have you taken part? (please indicate below)

Primary School □                                              Secondary School □

Local Authority Coaching Session(s) □    Club □

 

Other (please specify):

 

Medical Information

 

Please detail below any important medical information that our coaches/club should be aware

of (e.g. epilepsy, asthma, diabetes, a recent injury, etc).

 

Medical condition (s) and recommended treatment/actions to be taken if symptoms appear

 

Emergency Contact Details (to be completed by parent/carer)

Please indicate below the person who should be contacted in case of an incident/accident

 

Contact Name:                                                               Relationship to Child:

 

Emergency Contact Numbers

 

Home:                                                                           Mobile:

 

Notes

1.         It is part of the British Cycling Code of Conduct to ensure that reasonable steps are taken to establish a safe environment where young people can enjoy developing their cycling skills.

2.         Parents/carers are welcome to stay and watch the session but this is not compulsory.

3.         Young people are expected to remain in the session from beginning to end unless they have to leave early. If the young person has to leave early or is   being collected by someone other than the parent/carer, the parent/carer must advise the coach of the details of the arrangement, including who will be collecting the rider.

4.         It is the young person’s responsibility to participate in cycling activities in a sporting manner.

5.         Any young riders who persistently misbehave or put others in danger will be asked to leave the session.

6.         It is the parent’s/carer’s responsibility to ensure that their child’s bike is in a safe condition to ride.

7.         A correctly fitting cycling helmet must be worn at all times during the cycling activity sessions.

8.         For all children under 12 years, coaching sessions will take place at a traffic-free facility.

            Over 12s may be involved in coaching sessions that take place on the public highway.         Young people are only invited to take part when the coaches feel they are sufficiently responsible for their own actions and have developed the necessary bike handling skills and fitness levels in order to cope with riding on the public highways.

 

Please tick if you do not want your child to be involved in cycling activity sessions that take place on the public highways (See note 8 above). □

 

Parental Consent

I, being the parent/carer of __________________ have read the information contained on

this form and hereby consent to him/her taking part in the cycling activity sessions and

understand and agree that he/she participates in cycling activity sessions under the instruction of British Cycling qualified coaches entirely at his/her own risk. I have considered the nature of such sessions and have discussed them with him/her. I am satisfied that he/she is sufficiently responsible and competent to assume full and entire responsibility for his/her own safety under the supervision of a British Cycling qualified coach. I confirm that he/she does not have any disability or medical condition (not disclosed overleaf) that could affect his/her ability to participate safely in cycling activity sessions.

 

•           By returning this completed form, I agree to the child named above taking part in the

            activities of the club

•           I understand that I will be kept informed of these activities - for example timing and

            transport details

•           I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately

 

Name of Parent/Carer:

 

Signature of Parent/Carer:                                                          Date:

 

Once completed please return this form to:

 

Alistair Cameron, Treasurer, 29 Knox Street, Rodley, Leeds LS13 1LZ   with the appropriate payment, cheques made payable to Leeds Mercury CC, thanks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sports Equity Monitoring

 

Whilst it is not compulsory that this section is completed, the following paragraph explains why it is important.

 

Sport can and does play a major role in promoting the inclusion of all groups in society; however, inequalities have historically existed within sport, particularly in relation to gender, race and disability. British Cycling is committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of young people in our clubs we can identify any issues relating to under‑representation of different groups and can develop strategies to ensure that all young people have the opportunity to develop and progress in cycling.

 

Ethnicity - In order to help us monitor our membership, can you please tick one of the following boxes to identify your ethnic group:

  

White

 

British

□

Irish

□

Any other white background (please specify):

 

 

 

 

 

Black or Black British

 

Caribbean

□

African

□

Any other Black background (please specify):

 

 

 

 

 

 

Mixed

 

White and Black Caribbean

□

White and Black African

□

Any other Mixed background (please specify):

 

 

 

 

 

Chinese or other ethnic group

 

Chinese

□

Any other (please specify):

 

 

 

 

 

 

Asian or Asian British

 

Indian

□

Pakistani

□

Bangladeshi

□

Any other Asian background (please specify):

 

 

 

 

 

 

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