East Antrim Rambling Club		Application for Membership Annual Subscription Rates 2017-18 Single £25.00 Family £40.00
Name(s)
Address
					Post Code
Tel. (Optional)	Landline:			Mobile
Email Address (if available):
Membership Category (delete as required)			Single			Family

Please Make Cheques Payable to:-	East Antrim Rambling Club
Post applications to:-	Alastair Jack (Hon Treasurer) East Antrim Rambling Club 12 Glencroft Road, Newtownabbey, BT36 5GD
The following additional information is required to enable monitoring under Sport NI’s new Active Clubs Programme. Male/Female ………................ Ethnic Origin……………………………………………… Age Range (Please Tick): Under 18 ¨ 18-25 ¨ 26-40 ¨ 41-59 ¨ 60+ ¨ Do you consider yourself to be disabled? Yes ¨ No ¨ If yes could you expand on this? Mobility ¨ Learning Disability ¨ Hearing ¨ Visual Impairment ¨ Physical ¨
If the membership category is “Family” Sport NI’s monitoring information is required for the second person covered by the family membership Male/Female ………................ Ethnic Origin……………………………………………… Age Range (Please Tick): Under 18 ¨ 18-25 ¨ 26-40 ¨ 41-59 ¨ 60+ ¨ Do you consider yourself to be disabled? Yes ¨ No ¨ If yes could you expand on this? Mobility ¨ Learning Disability ¨ Hearing ¨ Visual Impairment ¨ Physical ¨

Date:-____________________________

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