Beginners Sign Up Form - Kippax & District Harriers

Name *

First

Last

Email *

Mobile

Home Phone

Home Address *

Date of Birth (DD/MM/YYYY) *

Emergency Contact Name *

Emergency Contact Phone Number *

Where did you hear about us?

What would you like to get out of the group

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

If Yes, what type and how often?

Do you currently have any health considerations we ought to know about *

If Yes, please provide details

Do you suffer from any of the following? (Please select all that apply)

Any condition requiring medication? *

Declaration *

England Athletics Leaders in Running Fitnesss 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.

Payment Confirmation

£25 - I confirm I will make the payment by bank Transfer

If for any reason you are unable to attend the course your £25 will be fully refunded as long as you inform us more than 7 days in advance of the start date. Unfortunately we can not make refunds after this time as all planning and arrangements will have been made and can not changed.