EmailMe Form - Canicross Cornwall Membership Form

Name

First Last

Date of Birth

MM / DD / YYYY

Phone

Mobile Phone

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Emergency Contact

First Last

Emergency Contact Phone

Your email address

Any known medical conditions please list below:-

Family Membership - Please provide names and dates of birth

Dog Details

	Name	D.O.B	Breed
Dog 1
Dog 2
Dog 3
Dog 4

Please list below any issues your dog(s) may have i.e. nervous/uncomfortable in certain situations and/or of unfamiliar people/dogs etc.

Yearly Membership Options

£25 Adult over 18

£40 (2 adults living at the same address )

I wish to apply for membership of Canicross Cornwall. I confirm that I have read the club constitution and fully understand the same. I accept that canicross can be hazardous and I participate at my own risk and Canicross Cornwall will not be held responsible for any possible injury/accidents.
The information requested on this form is confidentiaal and for emergency use only. In the event of an emergency while participating in any social or event in connection with Canicross Cornwall, the information will be used by personnel in an emergency. Please provide accurate, complete and true information.In case of an emergency, I give permission for my information to be released for emergency purposes. I also agree that any of my emergency contacts listed on this card may be notified in an emergency, as needed.

Signature:
Date: