Select Title (required)
---MrMrsMissMs

Your Full Name (required)

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Mobile Phone:

Home Phone:

Full Address including postcode: (required)

Date of Birth (required)
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Emergency Contact (required)

Emergency Contact Telephone Number (required)

Emergency Contact Address If Different From Your Own:

Where did you hear about us:

What would you like to get out of the group? (Please select all that apply)
Get FitterLose WeightRun EventsImproveMeet New Running PartnersOther

Are you currently involved in any other form/s of Exercise?
YesNo

If yes, What type and how often?

Do you currently have any health considerations we ought to know about? (required)
YesNo

If Yes, Please explain?

Do you suffer from any of the following? (Please select all that apply)
DiabetesHeart ProblemsJoint ProblemsHigh Blood PressureAsthmaBack PainPrevious InjuryOther

Any condition requiring medication? (required)
YesNo

The fee for the 12 week course is £16. Should you decide to become a full member on completion of the course, this amount will be discounted from the full membership fee.

Payment Method (required)
Bank Transfer (please see bank details below and make sure, your name is referenced)PayPal - please note there will be an £0.75 surcharge to cover PayPal costsCash or Cheque at Club

Declaration

Run England Group Leaders are qualified leaders and are willing to share their experience and enjoyment of the sport with me. I confirm that I understand that participation in this group is entirely at my own risk and should consult my own doctor if suffering from any condition that might make running injurious to my health.

By ticking this box, I confirm I have read and agree to the above declaration

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