Date of Birth*
2nd Member Name*
3rd Member Name*
4th Member Name*
5th Member Name*
Please indicate below the person who should be contacted in an emergency*
Relationship to Member(s)*
Please detail any underlying, recurring or present ailment or medical condition, however minor it may appear. ( E.g. Epilepsy, Asthma, Diabetes, heart or respiratory conditions, recent injuries, allergies etc.)
Medical condition(s) and recommended treatment/actions to be taken if symptoms appear: If you have any concerns about participating in any form of physical activity then please consult your GP before taking part in cycling activities or sessions.
Terms and Conditions*
by clicking this box you agree to abide by all the Terms and Conditions associated with becoming a Club Member, Our Rules and Cycling Ireland's Code Of Conduct (if under 18 years this must be clicked by a parent or guardian)
I confirm that photographs of me (or my child/family) can be used for promotional purposes
I agree that I'm a member of Lisburn BMX club, and if not I agree to initiate club transfer.
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Address: Bells Lane, Lambeg, Lisburn, BT27 4QJ
Facebook: Lisburn BMX Club