Registration Form

Personal Details = required

Full Name

Email Address

Alternate Email

Date of Birth

Membership Start

When would you like your membership to start?

As Soon As Possible Specific Date

Preferred Start Date
(if applicable)

Membership Category

Please select your preferred membership category

	Category	Cost
	Individual Only available to people aged 16 or over.	£5.00
	Reduced For those who feel they can't afford our full price individual, our Reduced membership offers all the perks of the regular Individual membership Only available to people aged 16 or over.	£2.50
	Household Up to 5 individuals in the same household	£10.00

Data Protection

I understand that any personal data I provide on this site will be processed in accordance with the Terms & Conditions and Privacy Policy. I have read and agree to the Terms & Conditions (https://www.myclubhouse.co.uk/YorkCycleCampaign/Home/TermsAndConditions) and the Privacy Policy (https://www.myclubhouse.co.uk/YorkCycleCampaign/PrivacyPolicy;).

Signature

Date

Please return completed forms to:

Use this form to send an email to another member. You may only send to one member at a time. Your registered email address will be passed on to this member but you may also include alternative contact details.

Note: Emails sent via the website are not entirely private. A copy of every email is held on the database and this can be accessed by the Campaign committee members using the Sent Emails page.

From

Alternative contact email

Another email address which the recipient can use to contact you.

Alternative contact details

Other contact details which the recipient can use to contact you e.g. phone number.

Subject

Message

Copy this message to my email address

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