JBR Tri Club Membership Application Form

JBR Tri Club Membership Application Form
Questions marked by * are required.
1.	Full Name *
2.	Email: *
3.	Gender?:
4.	Date of birth:
5.	Full Address:
6.	Next of kin and relationship
7.	Emergency contact number:
8.	Have you suffered or experienced any of the following tick for yes Chest pains Dizziness Fainting Migraine
9.	Have you recently recovered from an operation? Yes No
10.	Are you currently or have you recently been pregnant? Yes No
11.	Details1: If you answered yes to any of the above please give details here:
12.	Do you suffer from any following health conditions tick for yes Heart condition Asthma Stroke Diabetes High blood pressure Low blood pressure
13.	Any Bone or joint problems aggrevated by physical activity? Yes No
14.	To your knowledge are there any pains/conditions/disorders, which limit or restrict your physical movement? Yes No
15.	To your knowledge are there any reasons why you should not participate in physical activity? Yes No
16.	Has a Doctor ever recommended seeking advice before engaging in physical activity? Yes No
17.	Details2: If you answered yes to any of the above please give details here:
18.	List any serious injuries in the last 5 years
19.	Do you know your current 400m Swim time?* * 4-5 mins 5-6 mins 6-7 mins 7-8 mins 8-9 mins 10-11 mins 11-12 mins Not done
20.	Do you know your current 200m Swim time?* * 1-2 mins 2-3 mins 3-4 mins 4-5 mins 5-6 mins Not done
21.	Current 5km Time?* * 15-17 mins 17-19 mins 19-21 mins 21-23 mins 23-25 mins 25-27 mins 27-29 mins 29-31 mins 31-33 mins 33-35 mins 35 mins + Not done
22.	Current 10km Time?* * 35-40 mins 40-43 mins 43-45 mins 45-48 mins 48-50 mins 50-53 mins 53-55 mins 55-58 mins 58-60 mins 60-65 mins 65-70 mins 70 mins + Not done
23.	Current Half Marathon Time?* * 75-80 mins 80-85 mins 85-90 mins 90-95 mins 95-100 mins 100-105 mins 105-110 mins 110-115 mins 115 -120 mins 120-125 mins 125-130 mins 130-135 mins 135-140 mins 140-145 mins 145-150 mins 150 mins+ No done
24.	Current Marathon Time?* * 2hr 30 - 2hr 45 2hr 45 - 3hr 00 3hr 00 - 3hr 15 3hr 15 - 3hr 30 3hr 30 - 3hr 45 3hr 45 - 4hr 00 4hr 00 - 4hr 15 4hr 15 - 4hr 30 4hr 30 - 4hr 45 4hr 45 - 5hr 00 5hr + Not done
25.	Application Agreement I can confirm that all the information above is true and accurate to the best of my knowledge, by ticking the yes box i agree to abide by the club rules and constitution. I agree that my membership will not start until my payment has been cleared.* Agree Disagree