Adult Beginners Membership Form

[pic 1]

Adult Beginners Membership Form

We are very pleased to welcome you to Camden Fencing Club

To ensure we have the correct contact details for you, please fill out this form

and email it back to Patricia Aiyenuro. We will also use this information to ensure that you are kept informed about club events.

Name[pic 2]

Address[pic 3]

Postcode

Home telephone number[pic 4]

Mobile*[pic 5]

Email Address[pic 6]

Medical information

Please detail below any important medical information that our coaches/ Junior Coordinator should be aware of (e.g. epilepsy, asthma, diabetes etc.)[pic 7]

Emergency contact details

Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident.

Emergency contact number[pic 8]

Disability

The Disability Discrimination Act 1995 defines a disabled person as anyone  with ‘a physical or mental impairment, which has a substantial 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?[pic 9]

Please detail below any important medical information that our coaches/junior coordinator should be aware of

Visual impairment         Hearing impairment      Physical disability         Learning disability         Multiple disability          Other (please specify)[pic 10]

PREFERRED COURSE[S]

(A)   Beginners Sabre Course

Wednesday    7.00-8.20pm (£100 – six weeks) - Yes/No

(B)  Intermediate Sabre Course

  Wednesday    7.00-8.20pm (£100 – six weeks) - Yes/No

                Cost includes coaching at club plus supply of basic equipment if required.