MembershipFormV16Sept16

First Name: *

Middle Names:

Last Name: *

Date Of Birth: *

Address: *

Postcode: *

E-mail: *

Medical Conditions:

Home - Phone: *

Mobile - Phone: *

Work - Phone:

Membership Type: *

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Number: *

Membership Rationale: *

Please state your squash experience and your objectives in joining the Wessex Squash Club

Reference#1 Name: *

Reference#1 Address: *

Reference#1 Phone: *

Reference#2 Name: *

Reference#2 Address: *

Reference#2 Phone: *

Terms and conditions: *

I have read and agree to abide by the rules of the Wessex Squash Club

I wish to apply for membership of Wessex Squash Club

Passport Sized Photo: *