C25k Registration - Widnes Running Club

Title

Full Name *

First

Middle

Last

Date of Birth *

Enter your DOB in the format dd/mm/yyyy - for example 01/10/2000 for 1st October 2000

Address *

Full Address including Post Code

Main Contact Number *

Alternative Contact Number

Email *

Confirm Email

Medical Information

Do you have any medical conditions you think we should be aware of e.g. heart problem, asthma, diabetes or any allergies? (Any information will be treated in confidence)*

Next of Kin Name *

First

Last

Next of Kin Contact Number *

DECLARATION: I declare that I am an amateur according to EA rules *

Disclaimer *

I confirm that I understand that my participation in training sessions organised by the qualified leaders of Widnes Running Club at organised club sessions is entirely at my own risk and I should consult my own doctor if suffering from any condition that might make running injurious to my health.

Media Consent *

Do you agree to Widnes Running Club publishing photographs or running achievements that may include me or my name on social media.

Club Code of Conduct *

I confirm I have read and agree to abide by the Club's Code of Conduct

Digital Signature *

Please Type Your Full Name and Date of Birth