LONGFORD OFFSHORE SAILING ASSOCIATES             MEMBERSHIP APPLICATION and MEDICAL FORM    Please complete this form and e-mail it to, :-                           membership.secretary@losa-sailing.org.uk

 

 

I wish to become a member of LOSA and I agree to observe the rules of the organisation.

 

I declare that I will inform the Secretary immediately of any change in my medical condition or of any new medical information as it becomes available. I agree to the information given on this form being held on computer or given to persons who may be responsible for my safety according with the Regulations in the Data Protection Act.

 

Name:...............................................................................................................Date of Birth................................

 

Address: ...........................................................................................................................................................

 

.....................................Post Code:...................Tel.No.: ....................  e-mail:.....................................................

 

I have no/some sailing experience and have the following sailing qualifications:-

Please state whether the qualifications are theory/shore based or practical.

(Opportunities for sailing are NOT limited to people with experience or qualifications)..................................................

 

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I understand that the following medical information is given to ensure my safety and comfort.  LOSA

undertakes to keep to information confidential within the organisation.  I have the following condition/disability

(e.g.. MS, diabetes, epilepsy, angina):-

 

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and need the following medication/aids/diet (e.g. injections tablets, inhaler, and wheelchair):-......................................

 

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I need help with the following activities.....................................................................................................................

 

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In case of emergency (e.g. if unconscious), the following condition should be known about and this 

treatment should be administered:- ..............................................................................................................................................................................

 

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Please add any further information which you think officers of the organisation should know:-

 

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Next of kin ................................................................His/her telephone no.:- ....................................................

 

 

Signed..................................................................................Date..............................

 

Note.    Subscription Rates:-     Annual Membership  £15.00 (after Oct.1 this also covers the following year ).

Trial-day Temporary Membership £ 3.00.  If, after a trial sail, full membership is taken up, this fee may be

deducted from the annual subscription. Sailing fees are extra                                                                                       

 

 

 

 

 

 

 

 

Please complete the declaration below only if you have not done so before for LOSA

 

 

 

 

Gift Aid Declaration: Re. - LOSA - Registered Charity No.1030567

 

           

I confirm that I pay income tax at the Standard Rate and that the above Charity may reclaim tax on any donation or subscription I make after May 2004. I will inform the Charity if at any time I am no longer liable to income tax.

 

Name (Capitals)     __________________________________________

 

Address        _______________________________________________

 

                        _______________________________________________

 

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Signed           ______________________   Date   __________________