Application Form

Name

Date of Birth

Current Address (Incl. postcode)

Contact Name & Telephone Number

Telephone

Home

Other

Mobile

e-mail:

Medical Information (asthma,allergies)

Organiser

BT47 2AH

Phone: 07720 837100

Cost: £25

(Cheques payable City of Derry Athletics Club)

My child is in good health and I consider him/her capable of taking part in athletics. I consent that in the event of any accident/illness, any necessary treatment can be administered to my child, which may include the use of anaesthetics. I also understand that, while the coaches on star:track will take every precaution to ensure that accidents do not happen, they cannot be held responsible for any loss, damage or injury suffered by the child.

Parent / Guardian

Address if different from above:

Signed

Date