Club Membership Registration Form

Midleton AC Club - Senior Section New Members Application Form

Complete the form below to request 2021 membership.
2021 Fees:

Individual €40 - available until 31st January 2021

Couple €70 - available until 31st January 2021
Please select Individual or Couple Application *
Name *

First Name Last Name
Name2 *

First Name Last Name
E-mail *

Confirmation Email example@example.com
E-mail2 *

Confirmation Email example@example.com
Phone Number: *
Phone Number2: *
Address: *

Address Line1

Address Line 2

Town County

Postal Code
Birth Date: *

Day Month Year
Birth Date2: *

Day Month Year
Interests *

Road Running Track & Field Cross Country Social Events
Membership Rules
*

I agree to abide by the rules of Midleton AC
*

We agree to abide by the rules of Midleton AC
*

I agree to abide by the rules of AAI
*

We agree to abide by the rules of AAI
Privacy Policy
*

I agree to receive e-mails and texts from Midleton AC relaying club news and information.
*

We agree to receive e-mails and texts from Midleton AC relaying club news and information.
Photo Release
*

I hereby grant Midleton AC permission to use my image in good taste in promotional materials, posters, Web sites and other merchandise. I release Midleton AC from all liability of any nature in the use of any electronic or film image and or audio for advertising purposes.
*

We hereby grant Midleton AC permission to use my image in good taste in promotional materials, posters, Web sites and other merchandise. We release Midleton AC from all liability of any nature in the use of any electronic or film image and or audio for advertising purposes.
Medical Fitness
*

I am fully informed and aware that running and participating in club activities, including volunteering, are potentially hazardous. I understand I should not participate in any group activities (sanctioned or unsanctioned) unless I am medically fit and able to safely participate. I acknowledge it is my sole responsibility to ensure my level of medical fitness and do hereby declare that I am medically fit.
*

We are fully informed and aware that running and participating in club activities, including volunteering, are potentially hazardous. We understand we should not participate in any group activities (sanctioned or unsanctioned) unless we are medically fit and able to safely participate. We acknowledge it is our sole responsibility to ensure our level of medical fitness and do hereby declare that we are medically fit.
New members will be contacted shortly to confirm your membership application has been accepted. If you were a member of another AI club in the last three years, you need to contact that club secretary to initiate a transfer.

Midleton AC reserves the right to refuse membership applications.

Thank you!
Fee €

Payment Due *

EUR Please check you have selected the correct application type at top of form

Payment Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Midleton AC Club - Senior Section New Members Application Form

Membership Rules

Privacy Policy

Photo Release

Medical Fitness