Wivey Pool Membership Form 2012

Wiveliscombe Community Swimming Pool Club (WCSPC) Membership Form 2012
Applicants name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gift aid
TYPE OF MEMBERSHIP

Family membership includes up to 2 adults and 2 children, under 5’s are free.

Additional family members between the age of 5 and 17 can be added to a family membership at a further cost of £5 per child. Family members should be resident at the same address, Please enter the name and date of birth of under 5's.

PLEASE ENTER NAMES OF INDIVIDUAL MEMBERS BELOW.

INDIVIDUAL MEMBERSHIP CARDS WILL BE ISSUED AT THE START OF THE SEASON
Membership applied for
Adult member

First NameLast Name
Gold membership
Adult member

First NameLast Name
Gold membership
Junior member

First NameLast Name
Birth Date

MonthDayYear
Junior member

First NameLast Name
Birth Date

MonthDayYear
Additional junior

First NameLast Name
Birth Date

MonthDayYear
Additional junior

First NameLast Name
Birth Date

MonthDayYear
Additional junior

First NameLast Name
Birth Date

MonthDayYear
Additional junior

First NameLast Name
Birth Date

MonthDayYear
Total payment inclusive of any donation £
Please send payment to (Please do not mail cash):

Lois Clark, The Olde Mill House, 20 West Road,Wiveliscombe. TA4 2TB (Tel: 01984-624106), or hand to a committee member at the pool.

Cheques should be made out to 'WCSPC' Wiveliscombe Community Swimming Pool Club
Membership Declaration
Should be Empty:

Wiveliscombe Community Swimming Pool Club (WCSPC) Membership Form 2012