Please complete fully and return to.
Club Secretary: Michelle Lewis, Henllys, Newchapel, Boncath, SA37 0EH
Phone: 01239 841692 Email: michelle.lewis7@btopenworld.com Web: www.velo-teifi.org.uk
Surname .............................................. Forenames .....................................................
Address..................................................................................................................................
................................... .............................................................................................................
................................................................................................................................................
Postcode ................................
Phone (Home) ........................................... (Work) ........................... (Mobile) ...............................
Email .......................................................................................................................
Sex Male/Female Date of Birth ..................................................
Under 16s only
School .................................................................................... School Year .......................................
Next of Kin / Contact Details
Name .................................................................... Relationship ........................................................
Address if different from above ...............................................................................................................
Cycling Interests (Please tick each one that applies)
Road ...... Track ...... Time Trial ...... Cyclo-X ...... X-Country ...... Downhill ...... BMX ......
Other (Please Specify) .............................................................................................................
Subscription
I enclose as my subscription to Velo Teifi Cycling Club (cheques payable to Velo Teifi)
| Standard | £10.00 |
| In full time education | £5.00 |
| Family Membership | £15.00 |
MEDICAL INFORMATIONPlease give any information that may be relevant regarding illness, allergies, Diabetes, Asthma, Heart condition, etc. that the club should be aware of
Please note the club is run on a completely voluntary basis, and help is always appreciated. Please contact the club secretary at the address above.