Club Affiliation Form

Affiliation Form for Litherland Circuit Races

for 2012

NAME OF CLUB ____________________________________________________________

SECRETARY ____________________________________________________________

Address : ____________________________________________________________

____________________________________________________________

Post Code :___________________________

Contact telephone number(s) :__________________________________________________________

Email address : ______________________________________________________________________

Club representative to the League if different from above :

SECRETARY/CLUB CONTACT______________________________________________________

Address : ____________________________________________________________

____________________________________________________________

Post Code :___________________________

Contact telephone number(s) :__________________________________________________________

Email address : ______________________________________________________________________

Signed by : ____________________________________________________

Position in Club : _______________________________________________

Date : ________________________________________

Please complete this form and together with a cheque for £50.00 made payable to: Litherland Circuit League and forward to the LCL Treasurer: Paul Paterson, 50, Ennismore Road, Liverpool, L13 2AT

A list of events, results, League positions and news items will be shown on the Merseyside Cycling Development Group website:

http://www.merseysidecyclingdevelopment.org/ and then follow the link on the Home Page

Individual Affiliation Form

Individual Affiliation form for 2012

To the Litherland Circuit League

Sponsored by : www.highonbikes.com

High on Bikes Ltd., 11, Hurlston Court, Scarisbrick Business Park, Smithy Lane, Scarisbrick, Lancashire, L40 8HN Telephone: 01704 841529

Name
Address
Next of Kin Contact Telephone No.
British Cycling Licence No. & Category
Name of Club a member of
Email Address
Date of birth if under 18 years of age

Winners of events may be asked by the Sponsors to do an interview at the end of their race and also, they may take Photos/Video footage of the events. If, you have any objections to this please indicate by putting a cross in the box o

			Payment
For ALL D and E Youth Categories	Free £2	Registration Fee for the year 2012 Entry Fee per night of racing in 2012	Nil
Membership when a Rider's Club/Racing Team has affiliated to the Litherland Circuit League
Youth (A/B & C Categories)	£3 £3	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Juniors (Male and Female)	£5 £7	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Seniors - Male	£10 £10	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Women	£5 £7	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Private Membership - For Riders whose Club/Racing Team have not affiliated to the Litherland Circuit League
Youth (A/B & C Categories)	£5 £5	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Juniors (Male & Female)	£10 £7	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
Seniors (Male & Female)	£15 £10	Registration Fee for the year 2012 Entry Fee per night of racing in 2012
None Racing Membership	£10	Registration Fee for the year 2012

Copies of the League Rules and the League Points for each licence category available from the League Secretary, Andy Gibson

Signed By : ____________________________________ Date : ______________________

PARENT/GUARDIAN: I hold legal responsibility for ……………………………………….and is aged under 18 on the present application. I understand and agree that my son/daughter participates in events promoted under the BCF and the Litherland Circuit League rules entirely at his/her own risk. I have considered and understand the nature of such events and have discussed them with my son/daughter. I am satisfied that my son/daughter is sufficiently responsible and competent to assume responsibility for his/her own safety. I understand that my son/daughter participate in such events without any liability whatever on the part of the organisers or their promoting clubs, the Litherland Circuit League or their officials or members in respect of any injury, loss or damage suffered by him/her. I confirm that my son/daughter does not have any disability or medical condition physical or mental, which could affect his/her ability to ride safely as a racing cyclist.

If you do not want photos/video footage being taken of your child please indicate by putting a cross here o

Winners of events may be asked by sponsors to do an interview at the end of their race with a parent being present. If you have any objections to this happening please indicate by putting a cross in the box. o

Print Name : __________________________

Signed By : ____________________________________ Date : ______________________

List of events, results, League positions and news items will be shown on the Merseyside Cycling Development Group website:www.merseysidecyclingdevelopment.org/

The completed Form and affiliation fee (cheques should be made payable to Litherland Circuit League) and sent to Paul Paterson, 50, Ennismore Road, Liverpool, L13 2AT