Membership form

Please fill in the application form for 2017 and click submit to be taken to a payment page. All fields marked with an asterisk are mandatory. Do not use this form if you are an existing member wanting to renew, log onto the site and use the link against your user details.

*Name:
*Address line 1:
Address line 2:
*City / Town:
County:
*Postcode:
Telephone number:
Mobile telephone number:
*Email:
*Date of birth:
*Gender:
Male
Female
*Please use this box to disclose any current medical conditions that the club should be aware of, or enter 'none'
*Emergency contact (name and phone number):
*Type of membership:
Senior (18 and over) - £18.00
Junior (16 and over) - £9.00
Young Wheeler (under 16) - £4.00
Unemployed/student - £9.00
Household membership - £36.00
Non-cycling associate member - £9.00
Second claim member - £12.00

Note, unemployed/student application accepted on trust but subject to review at the discretion of the commitee.

First claim club (if applying for second claim membership):
Household application: please enter the forename and surname, gender and date of birth of the other members of your household
Male Female
Male Female
Male Female
Male Female
Male Female
Parental consent form (required if applicant is under 18)
*Name of parent
*Address of parent (full address please)
*Name of child's school
*I give parental consent: By ticking this box you agree to be bound by the parental consent rules.
*Club rules and regulations By ticking this box you agree to be bound by the rules and regulations of the Chippenham Wheelers cycling club
Please type the following 4 digits into the box 0374