Membership Form

Number of Days

Activity

Sport and active recreation

Active travel e.g walking or cycling to work etc.

Work as part of paid employment e.g labouring or farming etc.

Domestic e.g. housework or gardening etc.

Please click here to print our membership form then close this window to return to the website.

Office use only

Membership Number ..............

Payment received ...................

Information processed ...........

Photograph received ..............

Membership Form

1. Personal Details

Name	............................................................................................

Address	............................................................................................

	.....................................	Post Code	.............................

Telephone	.....................................	Mobile	.............................

Email	.....................................	Gender	.............................

Date of Birth	............................................................................................

2. Medical Information

Please detail any important medical information that our coaches should be aware of (e.g. asthma, epilepsy, diabetes, etc)

....................................................................................................................

Does this limit your ability to be active in any way?

....................................................................................................................

3. Emergency Contact Details

In case of an incident/accident we should contact :-

....................................................................................................................

Have you taken part in any physical activity during the last 12 months?

(This includes recreational activities like walking, cycling, swimming etc, but does not include P.E. lessons in school, or domestic activities such as gardening or housework, or active travel such as travelling to work by cycling or walking.)

Yes	No

5. a)

How many days a week do you take part in 30 minutes of moderate intensity physical exercise?

(Moderate intensity exercise is any type of physical activity that makes your breathing & heartbeat faster and you feel warmer. This includes P.E. lessons in school, domestic activities & active travel).

Number of Days
0	1	2	3	4	5+

5. b)

How many days a week do you get 30 minutes exercise from each of the following activities? (Please tick one box in each row)

Please tick this box if you would prefer not to have your photo / video taken during Club 24-17 activities

I confirm the above details are correct.

Signature

..............................................

Date

...........................

Please allow 5 working days for your membership card to arrive.

Please be assured your personal details will be kept confidential.

Return forms along with payment and passport photo to :-

Club 24-17, Active Futures, Pickaquoy Centre

Kirkwall, Orkney, KW15 1LR

Please make cheques payable to

The Pickaquoy Centre