LeRoc Surrey Club Membership Registration Form

New LeRoc Surrey Club Membership Registration

Complete the form below to sign up for our membership service. All dancers are required to be registered members under our current Public Liability Insurance Cover, who wish to attend LeRoc Surrey indoor events. Memberships cards must be produced at every event.
This form is also for existing members who have misplaced their membership cards.

Once a member, the membership number is unique to you.

£1 per card replacements.
Name*

First NameLast Name
Main Email*
Alternative Email or repeat main email here please*
example@example.com
Phone Number:*

Area CodePhone Number
Mobile Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

TownCounty

Post CodeCountry
Birth Date:*

MonthDayYear
I am requesting:*

New MembershipReplacement Membership card (£1)
My existing Membership Number is (enter below), for a replacement card. Non member if applying for a new membership, not replacement, enter "XXX")
Where did you hear about us?*

A Friend or colleagueGoogleAdvertNews ArticleDance SiteFacebook
Who referred you to LeRoc?*
What was your address (if different from above) when you became a Member if you are looking for a Replacement card, so we can locate you, when names can be indentical ?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership Rules
1. Membership is available to anyone 18 years of age or older.

2. You agree NOT to use to conduct any fraudulent or business activity or have more than one Member Account at any time.

3. LeRoc Surrey (The Jive In Dance Co) teaches a fun and social dance, however LeRoc is an athletic and aerobic exercise. Although all efforts are made by LeRoc to ensure my safety, you understand that LeRoc can accept no responsibility for any loss or injury to persons or property while attending any LeRoc Events.

4. You agree not to us talc or any substitute substances are banned on all LeRoc venue floors due to Health & Safety requirements.

5. You are completely truthful with the details you are required here to complete and any information provided that is found to be false, will result in a lifetime ban and maybe reported to the authorties for misrepresentation.

6. You must show your membership card at Check In, at all times, to enter any of our venues. Requirement by our Insurance Company since March 2020.
To become a LeRoc Surrey Member.*

I have read, understood, and accepted the rules for membership.
Privacy Policy
Please read our Privacy Policy in order to understand how your information is used and shared, and check below if you accept the policy.
LeRoc Privacy Notices, click on the

Link
Privacy*

I have read, understood, and accepted the PRIVACY POLICY for membership.
Once you submit your application, we will contact you shortly to inform you of your online membership number. Please bring this along to a LeRoc Surrey dance venue after Covid 19 restrictions are lifted as we are unable to process this at the venues at this current time.

Thank you!
LeRoc Office use only
Should be Empty:

New LeRoc Surrey Club Membership Registration

Membership Rules

Privacy Policy