APPLICATION FOR MEMBERSHIP
Please print out, complete and send by post, or deliver by hand to the address at the bottom of the page. Contact us by email: secretary@stokeac.org.uk if you want to know more. If changing clubs please check out the information at the Midland Counties AA

Full Name: …………………………………………………….………………………..................

Address: ………………………………………………………………………………..................

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Postcode: ……………………………………..

Telephone Number - Home: ……………………….......... Mobile: ………………..................

Date of Birth: …………….…………………………........................

Email Address: .......................................................................

Medical information, including medical conditions, allergies, special needs:
 
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School attending: ........................................................................................................

Your event(s): .............................................................................................................

Signature: ..................................................................................................................
(If under 15 - name and signature of parent or guardian)

I hereby apply for membership of City of Stoke Athletic Club. I declare that I am an amateur in accordance with the rules laid down by the governing body.

• I request membership on a first claim basis and I do not belong to any other athletic club.
  
  
• I request membership on a second claim basis, my first claim athletic club being: 
  
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  (Delete whichever is not applicable)

Data Protection: Information collected above will be solely used for the purpose of activities associated with the administration of the City of Stoke Athletic Club.  

City of Stoke AC Secretary
The Pavilion, Northwood Sports Centre, Cromer Road, Stoke-on-Trent, Staffs, ST1 6QN