PALMERSTON NORTH ATHLETIC AND HARRIER CLUB

APPLICATION FOR MEMBERSHIP 2010/2011

NAME:

ADDRESS:

PHONE:

Home

( )

PHONE:

Cellphone

( )

PHONE:

Work

( )

E-MAIL:

DATE OF BIRTH:

/

/

MALE/FEMALE:

GRADE:

(see table below)

SUBSCRIPTION FEES:

I agree to my details being put into a database and used for the purposes of the Palmerston North Athletic & Harrier Club only

SIGNED:

PARENTS:

I agree to assist on ONE club night per month

PARENT'S SIGNATURE___________________________