/ Kettering
Cycling Club /
Membership Application
Please complete and return this form to the club secretary – details can be found on the website.
Name:
Address:
Postcode:
Gender: / Date of Birth:
Tel (Home):
Tel (Mobile):
Email Address:

Emergency Contact

Please give details of the person who should be contacted in case of an incident/accident
Contact Name:
Tel (Home): / Tel (Mobile):

Other Clubs

If you are a member of another cycling club, please give details
Club: / Will Kettering CC be your 1st claim (main) club?

Disability and Medical Information

Please give brief details of any disability or medical condition you feel the club should be aware of, and describe any recommended treatment or actions.

Your Membership

Membership runs from 1st January to 31st December. Payment will be requested on receipt of your membership form – we prefer online payments but also accept cash or cheques. Membership applications received on or after 1st August are free for the current year.
Fee / Tick (x)
Senior
Over 18 on 1st January. / £15
Junior
Under 18 on 1st January. If under 16 please also complete a Parental Consent form. / £6
Family
Up to 2 adults and 2 children.
NB. Please complete family member details on page 3 / £20


Declaration

I declare the above to be correct and that I am an amateur as defined by the rules of British Cycling and Cycling Time Trials organisations.
If my medical circumstances should change in the future I will notify the club officials of any condition or disability that they may need to be aware of.
I understand that I will from time to time be expected to provide help at club events.

Please tick (or x) here: if you are happy to receive newsletters and other updates via email.
Signed: Date:
NB. If applying by email no signature is required


Family members

If you are applying for family membership, please give details of family members

Name:
Gender: / Date of Birth:
Tel (optional): / Email (optional):
Please give brief details of any disability or medical condition you feel the club should be aware of, and describe any recommended treatment or actions.
Name:
Gender: / Date of Birth:
Tel (optional): / Email (optional):
Please give brief details of any disability or medical condition you feel the club should be aware of, and describe any recommended treatment or actions.
Name:
Gender: / Date of Birth:
Tel (optional): / Email (optional):
Please give brief details of any disability or medical condition you feel the club should be aware of, and describe any recommended treatment or actions.
Parental Consent
For anyone under 16, the declaration below must be completed by a parent or guardian. Please see notes on page 4 for more details
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). □
Parental Consent
I, being the parent/guardian of the above-named child(ren), have read the information contained on this form and consent to them taking part in the cycling activity sessions. I understand and agree that they participate in cycling activity sessions under the instruction of British Cycling qualified coaches entirely at their own risk. I have considered the nature of such sessions and have discussed them with them. I am satisfied that they are sufficiently responsible and competent to assume full and entire responsibility for their own safety under the supervision of a British Cycling qualified coach. I confirm that they do not have any disability or medical condition (not disclosed overleaf) that could affect their ability to participate safely in cycling activity sessions.
Signature of Parent/Guardian:….…….……………………………………………………………………………………………………..
Name of Parent/Guardian: ……………….………………………………………………………………..Date:………………………..


Parental Consent 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 coach must be informed 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/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.
• By returning this completed form, I agree to the child(ren) 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.
If you have any concerns about the child participating in any form of physical activity please consult your GP before giving permission for them to take part in cycling activity sessions.

Privacy Policy

What information do we hold?
·  We keep hard copies of the membership forms you complete when you join
·  Paysubsonline is the online payment system we use – we store your name, date of birth, address, phone numbers, email address and emergency contact details in its database
·  The CTT time trial start sheets we use require your name, address and an emergency contact
·  Time trial and other race results are held on the club website
Who can see information about you?
·  Your details may be shared with club officials – club secretary, committee members and other officials as necessary
How long do we keep your information?
·  While you’re a member and for two years after you let us know you’re leaving
·  CTT rules specify that we keep sign-on sheets for seven years
Do we share your data?
·  We share statistics (eg. numbers of members in certain age bands) with British Cycling but we don’t share names or any other details that could identify any of our members
Security
·  Access to Paysubsonline is by username and password only
·  Only committee members and club officials will be given rights to view other members’ details
·  Any data exchanged between club officials will be password protected
What about social media?
·  KCC have pages on Facebook, a Twitter account and a club in Strava, but anything you post or share on those sites is your own responsibility

page 4

membership form version 2.1 30/04/18