Student Membership Application Form

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Pontblyddyn CC

Home
About
Membership
Club Policies and Safeguarding
Sponsors
Contact
Club Management Committee

info@pontblyddyncc.org.uk

Tel: 01352 748460

Pontblyddyn Cricket Club

Over 18 - Student In Full-time Education - Membership Application Form - 2025

Fees: £50 (one off payment) or 6 monthly direct debit payments of £10 (Total £120)

All the fields require completion unless marked optional, if the form will not submit - please check that you have completed all the required fields, any fields marked red will require completion.

Senior - Over 18 (Student) Membership Application Form

First Name:

Surname

Street Address

Town

County

Post Code

Email:

Phone:

Date of birth

Gender

Do you suffer from any of the following

Epilepsy

Heart Trouble

Asthma / Breathing difficulties

Allergies (details below please)

Other condition (details below)

None

Please enter any additional details of medical conditions or any other medical or medication information that you feel is relevant in the space below

I confirm that I have provided all the medical information that I feel is relevant in relation to the participation of activities at Pontblyddyn Cricket Club

Yes

No

Emergency Contact Name

Emergency Mobile No.

Emergency Work No.

Emergency Home No

Do you consider yourself to have a disability?

Yes

No

If Yes, what is the nature of your disability?

Visual Impairment

Hearing impairment

Mobility Impairment

Learning Impairment

Other (please provide details)

Please enter any additional details of disability that you feel is relevant in the space below

Acceptance of the club terms of membership

By accepting the terms of membership, you are providing consent that you have read and understand the club policies and privacy statement and accept them as part of your membership. Any breach of the club rules and or policies will result in disciplinary action being taken, which may result in your membership of the club being revoked..

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Home
About
Membership
Club Policies and Safeguarding
Sponsors
Contact
Club Management Committee

Contact info:

01352 748 460

info@pontblyddyncc.org.uk

Alder Meadow,

Wrexham Road,

Pontblyddyn,

Flintshire.

CH7 4HW

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