Application for Annual Membership
Kilkenny City Harriers
DATE OF BIRTH / / . GENDER- MALE/FEMALE
Mobile Phone Number(If over18)_______________________________________________________
Email Address (If over18)___________________________________________________________________________
Second Child (if Applicable)
Date of Birth: / / . GENDER - MALE/FEMALE
Third Child (If Applicable)
Date of Birth / / . GENDER - MALE/FEMALE
Fourth Child (If Applicable)
Date of Birth / / GENDER - MALE/FEMALE
Parent / Guardian Information
I am the Parent / Guardian of _____________________________________________
Mobile Number: __________________________ Home Number: ___________________________
E-Mail Address: ____________________________________________________________________
Medical History & Consent Form
Please provide details of any known allergies and medical conditions the member(s) have. Please provide details of any medication that may be relevant to Anti-Doping regulations. If you are unsure, please speak with any of our coaches who will advise you further.
Are there any other special needs / requirements or directions that would be helpful for leaders / coaches:
In the event of illness or accident, having parental responsibility, I give permission for medical treatment to be administered where considered necessary by a nominated first aider, or by suitably qualified medical practitioners. If I cannot be contacted and my child needs emergency hospital treatment, I authorise a qualified medical practitioner to provide emergency treatment or medication.
Photographs and Film
I understand that photographs or film may be taken during or at sport related events and may be used in the reporting or promotion of the sport. If you do not wish your child to be photographed or filmed, please advise the club’s Child Liaison Officer.
Membership of Athletics Ireland means that all athletes may be chosen for testing. Your membership of Athletics Ireland commits you to agreeing to testing and in the case of a Child (U/18) the prior written consent of the parent / Guardian is required via the initial membership process at Club level, or at selection for competition or through competition entry forms. All club personnel have a responsibility to ensure that club members are aware of the Irish Anti-Doping Rules and that there is an atmosphere supporting a drug free sport within the club. A complete copy of the Irish Anti-Doping Rules is available through the Athletics Ireland website. Once you become a member of Athletics Ireland and enter a competition you are accepting the fact that you could be drug tested.
I hereby consent to the above child(ren) participating in activities of the organisation in line with the Code of Ethics for Younger People. I will inform the leaders / coaches of any changes to the information above.
Signature of Parent / Guardian: _______________________________ Date: _______________
I will have fun, make friends and learn about athletics from my coaches and mentors.
I agree to the rules of the club and to train to the best of my ability and compete for the club.
I agree to accept coaching from the club and to behave in an appropriate way at all times.
I agree to help out and take part in fundraising activities for K.C.H.
I agree to abide by the code of conduct for children and athletes.
Athlete Signature(s) _______________________________ _______________________________
Parent Signature(s) _______________________________ _______________________________