the Ulster Canoe Club

CANI Membership (if applicable)

Contact Details:

Address:

Medical and Emergency

Gender:
Date of Birth

Next of Kin

Someone we can contact in the event of an emergency:
Emergency phone contact 1:
Emergency phone contact 2:

Doctor's name:
contact number for your Doctor:
Address of your Doctor

Are you currently undergoing any medical treatment?
Please provide a brief description of the effects of any disability or medical condition and of any particular needs you may have.
Any allergies e.g. Food, medication, anaesthetics etc?
Date of last anti-tetanus injection (if known) ?

Experience and Qualifications

Paddling Experience:
British Canoeing Awards. Star awards only act as a guide. You may have no stars and be an intermediate or advanced paddler.
British Canoeing coaching Awards:

Declarations

	 1.) Canoeing is a water based activity that may carry attendant risks.  Participants in these activities should be aware of and accept risks such as, danger of personal injury or death and be responsible for their own actions and involvement.

      2.) I acknowledge that canoeing is an extreme sport undertaken at my own risk I can confirm I do not suffer from any disability or medical condition that may render me unfit for strenuous exercise.* I understand that Ulster Canoe Club cannot be held for any personal injury loss or damage as a result of my participation in any club event except that which is the result of gross negligence and/or wilful or wanton misconduct.

      3.) I declare that I have not at any time, within the United Kingdom and its dependencies, or in any other country of territory, been found guilty by a court of any offence concerning children or young people under 18 years of age, nor bound over, placed on probation, caution, or discharged conditionally or absolutely in relation to such offences I understand that I must inform the committee should this position change at any time.
	
	I agree to be bound by the rules and regulations of the association and the British Canoe Union. 
    I accept liability for my/our share (£1) in the company in the event of liquidation of the Union.    
		
		*Should a medical condition exist this will not necessarily preclude you from membership or participation but it must be declared. Should you be in any doubt advice should be sought from your family doctor.

Please indicate that you agree with the Declarations:

Photographs will be taken to promote canoeing and club activities. If you do not want your image to be used for publicity and promotion by the Ulster Canoe Club, Make Your Own Adventure, the Canoe Association of Northern Ireland and/or British Canoeing on websites, printed material and on social media, please say so below:
Please Do not complete the Following if you are a full CANI member:
If so, please supply your previous number

Equality Monitoring

This section shall be retained separately and only used for the official purposes intended. Please select the options that are relevant to you. All information collected will be stored within the data protection guide lines.

Gender:
National Identity: What do you consider your national identity to be?

Ethnic Origin: To which of these ethnic groups do you consider you belong? (Please select the option that is most appropriate for you)

Community Background: Please indicate your community background from the dropdown list.

Do you consider yourself to have a disability or medical condition?

Yes

No

What is the nature of your disability?