Senior Membership Application Form OAC Senior Membership Application Application form for new senior members Orangegrove AC Privacy Statement*When you become a member of or renew your membership with Orangegrove Athletics Club you can also choose to be registered as a member of Athletics Northern Ireland (you will have to register with Athletics Northern Ireland if you ever compete for the club in competition). If you tick the box on the below, we will provide Athletics Northern Ireland with your personal data which they will use to enable access to an online portal for you. If you do not tick the box and then later decide to compete for the club, we will need to register you with Athletics Northern Ireland and we will inform you at that time. You can also read the club privacy notice on our website - http://orangegroveac.co.uk/our-club/club-policies/ I agree to OAC providing my personal data to ANI Your DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Name Last Name Date of birth* Gender*MaleFemaleAddress* Street Address Address Line 2 Town/City County Post Code PhoneMobile PhoneEmail* Enter Email Confirm Email Medical DetailsMedical Consent*Any special category health data we hold on you is only processed for the purpose(s) of passing health data to coaches and club captains to allow the safe running of training sessions. I agree to my medical information being passed on to OAC coaches and club captains Medical InformationPlease indicate any medical condition/medication that the club should be aware ofDisabilityThe Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’Do you consider yourself to have a disabilityYesNoWhat is the nature of your disability? Visual Impariment Hearing Impairment Physical Impairment Learning Disability Multiple Disabilities Other For 'other' Please Specify*Further Disability DetailsPlease provide any additional information which you consider relevant to your disability which would assist coaches to ensure that you are fully supported at the clubEmergency Contact Details (ICE)ICE Contact Name* First Name Last Name ICE contact relationship to you*ICE contact phone number*This may be a mobile phone numberICE contact mobile phone numberAthleticsVisit our website for an overview of the membership types -http://orangegroveac.co.uk/our-club/membership/ and for full explanation of Second claim membership see UKA Rules for Competition (Rule 21) - https://www.uka.org.uk/competitions/rules/Membership Type*Which membership type are you applying for? Senior CompetitiveSenior Non-competitiveSenior competitive Second ClaimAssociate MembershipWhat is the name of your First Claim Club?*Training HistoryPlease indicate below your areas of interest i.e Track and Field Middle Distance, Marathons, Fell Racing, Cross Country etc along with any known PBsPrevious Club membershipIf you have recently left another athletics club, please provide the date of your resignation. You may need to complete a Transfer of Club Membership Form -https://athleticsni.org/Clubs/Athlete-TransfersDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Declaration* I agree to abide by the OAC's club rules / policies including the codes of conduct. The Club rules and code of conduct can be found on the club website - http://orangegroveac.co.uk/our-club/club-policies/SignaturePlease type your full name to provide a digital signatureEmailThis field is for validation purposes and should be left unchanged.