Raheny Shamrock Athletic Club Registration Form 2012

 Name: …………………………………………………………………………………

Address:…………………………………………………………….

Date of Birth: ………………………….….

School (if juvenile)………………………...................................................................

 Home Phone No.: ……………………….. Mobile Phone No.: ……………………..

E-Mail Address:…………………………………………………………………………

Any Medical Conditions?  ……………………………………………………………………… 

Do you or have you ever suffered from any unexplained fainting, collapsing or fits?

Yes      □                     No        □

If yes, please give details:

………………………………………………………………………………………………

 Subscriptions  

Individual Juvenile Member U13 (Manor House Group only)     € 70.00

Individual Juvenile Member U14-U19, Junior U20, Student           € 90.00

Individual Senior Member                                                                 €100.00

Family Membership                                                                             €180.00

Note: Family membership maximum 4 people - 2 adults & 2 children/1 adult & 3 children or 4 children.  The relevant individual subscription must be paid for each additional family member. Complete a separate form for each member.

 If accepted, I agree to abide by the rules of the club. I also understand that the club, its coaches, its members and committee shall not be held responsible for any accidents or injuries sustained by me, from any cause whatsoever or however arising, or for any property mislaid or stolen in the club or its environs. I agree to allow photographs and videos of myself in training and competition to be taken occasionally and posted to the club’s website.

 Applicant’s Signature: ……………………………………               Date:…………………….

 (Juveniles Only)

Parent’s Names:…………………………………... . Parents Signature………………………………