Personal Details:

First Name: *    Surname: *

Date of Birth: day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year *

Preferred Name:        

Home Tel No:     Work Tel No:   

Mobile Tel No:        Please enter at least 1 telephone number

E-mail:  *

Your Address:

Number or House Name     *

Street          *

Town           *

County        *

Postcode    *

Country       *

Your Interests:

Please check all relevant boxes:

Walking      Rock Climbing      Scrambling      Ice Climbing      Caving  

Skiing      Snowboarding      Mountain Biking      Gear Shopping    

Kayaking  

Other     Please specify  

Please tell us about yourself and your general experience level:

Are you a member of any other
mountaineering / walking/ rambling clubs?

Are you a BMC/RA Individual Member?

Participant statement: I am applying to join the Lanchester Mountaineering
Club. I recognise that climbing and mountaineering are activities with danger
of personal injury or death. In participating in these activities I am aware and
accept these risks, and am responsible for my own actions and involvement.
I have read the club constitution and agree to be bound by it and any
subsequent amendments to it. If I have any medical condition or am taking any
medication whilst on a club activity, I will ensure that a member of the immediate
group is aware in case of an accident occurring. I have informed my next of kin
of my involvement with this club, and of the precise contents of this participation
statement.

I confirm that I agree to the above statement         no yes   *