Membership Details 2010

Please fill out this form AFTER you have completed the paper membership form & paid your dues at the club.

Hiking, Climbing, Mountaineering are inherently dangerous sports. This information could prove useful!

Your Contact Details

First Name : Last name:

Additional Names (if Family Membership):

Email Address(es):

Tel (Home): Tel (Work): Tel (Mobile):

Residential Address (No PO BOX's): Town:

Membership Category & Cards

       Full Ordinary Individual
       Full Ordinary Family
       Overseas Ordinary
       Student
       Corporate
       Life Membership

Do you have a membership card(s)?
YES NO

Information & Member Details (*NEW*)

      Nationality: Spouse Nationality (if different):

      Next of kin (or other emergency contact):
      Name: Relationship: Phone number(s):

Blood Group: (if known) Serious Allergies:

Medical Insurer: (if insured) Phone Number:
Evacuation Insurer: (if insured) Phone Number:

                  Optional Information:
Would you be willing to assist in the event of an emergency? YES NO

                  If YES, please answer these additional questions:

Are you an experienced: Rock-Climber? YES NO      Ice-Climber YES NO

                  If YES, Do you have your own equipment? YES NO

Do you have medical skills / qualifications? (Doctor, Nurse, experienced / qualified first-aider?)

Do you have any other skills or equipment which may be of use in a hiking / climbing emergency?

Comments & Suggestions for YOUR Club