ĐĎॹá>ţ˙ dfţ˙˙˙c˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ` đż0bjbjć‡ć‡ 14„í„í˙˙˙˙˙˙¤¨¨¨¨¨¨¨ź@@@@TDź‰Z~¤¤¤¤¤¤¤¤Z Z Z Z Z Z Z$\ho^|.Z¨IK¤¤IKIK.Z¨¨¤¤CZ L L LIK ¨¤¨¤Z LIKZ L LŽÜXh¨¨ĐY¤˜ °˙’ď-Ĺ@SKRDYZYZ0‰ZTY|ë^ĽKRë^ ĐYë^¨ĐY8¤˘F,˜ LŢ8 ňBW¤¤¤.Z.Z÷K¤¤¤‰ZIKIKIKIKźźź„@źźź@źźź¨¨¨¨¨¨˙˙˙˙ SHIA SPORTS PETERBOROUGH MEMBERSHIP APPLICATION FORM Applicant's Name Mr/Mrs/Miss: ………………………………………….…………………………………………………………………........................ Date of Birth: …………………………………………………………………………..…………………….…………………………… Telephone: Home: ………….……………..…… Work: ……….……………………..… Mobile: …………………........ E-Mail: …………………………………………………………………………………………………………………….. Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)...……………………………………………………… Spouse’s Name: Mr/Ms/Mrs: ……………………………………………………………………………………………………………………………… Date of Birth: ………………………………………………………………………………..…………………….……………………… Telephone: Home: ………….……………..…… Work: ……….……………………..… Mobile: …………………........ E-Mail: …………………………………………………………………………………………………………………….. Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)..……………………………………………………… Full Address: ……………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………….……….. Children’s Details: Name: ……………………………………………… Date of Birth: ………………………M / F Contact / E-mail address: …………………………………………………………………………... Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)..……………………………………………………… Name: ………………………………………………Date of Birth: …………….……… …M / F Contact / E-mail address: …………………………………………………………………………... Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)..……………………………………………………… Name: ………………………………………………. Date of Birth: …………………….. M / F Contact / E-mail address: …………………………………………………………………………... Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)..……………………………………………………… Name: ……………………………………………….. Date of Birth: …………………… M / F Contact / E-mail address: …………………………………………………………………………... Area of Interest: (Please circle) Badminton Cricket Darts Football Golf Net Ball Squash Swimming Table-Tennis Tennis Volley-Ball Other: (Please specify)..……………………………………………………… Contact in case of emergency: Name: ………………………………………………………………………………………………. Telephone: ………………………………………………………………………………………….. Relationship with Applicant: ……..................................................................................................... Doctor’s name: …………………………………………………………………………………….. Surgery Tel No: ………………………………………..................................................................... Address: ……………………………………………………………………………………………. DO YOU or ANY OF THE ABOVE NAMED APPLICANTS HAVE A MEDICAL CONDITION WE NEED TO BE AWARE OF? YES/NO IF YES, PLEASE GIVE NAME OF PERSON AND FULL DETAILS: (If more space is required, please use a separate page and attach it to this form) …………………………………………………………………………………………..…………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………….... ………………………………………………………………………………………………………………… Please consider the suitability of any event/sport and always consult your doctor before registering. Applicant’s Disclaimer: I hereby apply to for the following Membership: (please circle) Option 1 Option 2 Option 3 Family Single (18+) Youth (13-17) Children (5-12) I certify that: - I will comply with the Constitution of Shia Sports & Husaini Islamic Centre, Peterborough - I understand that Shia Sports will organise events and provide the facility for those events to take place in only. They are not responsible for our safety and our children’s safety. It is our responsibility to either accompany our children or appoint an Adult to supervise them throughout the duration of the sessions. I understand that Shia Sports will take every possible care to ensure that we do not get injured during play, but should we or our children get injured, Shia Sports or the Jamaat cannot be held responsible. They are not liable for any consequential, indirect or special damages and/or injuries caused to us or to our belongings. We indemnify them for claims caused by us. Signature of Applicant: …………………………………………………….. Data Protection Disclaimer: All information collected will be used only by and will only be made available to Shia Sports. No attempt will be made to disclose your personal details to anybody outside Shia Sports. -------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY Application Received on: …………………………………………………………………………... Payment received cheque / cash: …………………………………………………………………... 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