Purpose of this membership form is to gather information and built a data base for Albanian community in the UK, to help memberís involvement in GCSE project, education, research.

Membership FORM

Applicant Information

Parents Name/Surname

Date of birth:

 

Phone:

Current address:

Employment Information (optional)

Current employer:

Employer address:

Position:

Phone:

E-mail:

Fax:

NUMBER OF children in the fAMILY

Name/Surname

Age

Gender (M/F)

Name of School attending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL INFORMATION & CONSENT, In case of emergency and as part of the school responsibility to its membership.

(To be completed by PARENT or GUARDIAN if under 18), Details will be held securely with access restricted to authorized officers only.

 

NEXT OF KIN

 

MOBILE PHONE

 

DOCTORS NAME

 

PHONE

 

As far as you are aware, are you allergic to medication? (If YES Please state)

Are you taking any regular medication? If so, for what reason?

Do you have any long term illnesses or injuries?

Declaration: I consider myself (my son/daughter)* to be physically fit and capable of full participation and agree to notify the club of any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission (for my son/daughter)* for the teachers appointed by Ardhmeria to obtain emergency medical treatment on my behalf.

SIGNED

 

DATE

 

(RELATIONSHIP)

 

Signature of applicant:

Date:

 

All the information on this membership form would be treated strictly confidential.

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This form should be returned to: Director of Ardhmeria

Unit 106, Camberwell Business Centre

99-103 Lomond Grove,

London SE5 7HN

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www.ardhmeria.co.uk, e-mail: lutfivata@yahoo.com

Registered charity in England and Wales No 1118989