Daventry Raynet Group
Membership Application Form
Please complete in block capitals using Black Ink and  supply 1 Passport style photo
PERSONAL DETAILS

First Name:
 

Surname:
 

Address:
 
 
 

Post Code:

Home Phone No

Work Phone No:

Mobile No:

E-mail Address:

Availability:
            Any time Y/N              Saturdays  Y/N              Sundays Y/N               Not during week Y/N

         Not during working hours Y/N                       Not at night Y/N

 Comments:
 
 
 
 

Any training/skills which may of benefit in emergency:
 
 
 
 
 

Any Medical Conditions Or Allergies We need to know about:
 
 
 
 
 

D.O.B (if under 18)

Next Of Kin:
 

Contact Details:
 
 

Mobile Tel No:

Car Driver:      Y/N

VEHICLE TYPE
Make:                                              Model:                 Reg. Number:
 

EQUIPMENT DETAILS
You Will Be Expected To Carry A Minimum Of: Raynet ID Badge, Radio, Notebook & Pencil,
Hi-Vis Raynet  Jacket,  TorchPlease state below what else you will be carrying
 

COMMUNICATIONS

       26 MHz Y/N        27 MHz Y/N           Handheld Y/N          Amateur Radio Y/N        Connector Y/N

Your Call Sign:___________________________

SAFETY
Fire Extinguisher: Y/N         First Aid kit: Basic Y/N      Comprehensive Y/N

TOOLS
Basic kit Y/N        Comprehensive Kit Y/N

Additional Equipment I Will Carry
 
 
 

DECLARATION

DATA PROTECTION: I understand that The information supplied on this form will be held both manually and electronically for the use of (elected) officers of the above club.  The information will not be passed to other bodies without my express permission.  My signature below confirms that this is entirely acceptable to me. I also am aware that I may rescind this authority at any time.
 

Signed ____________________Print ______________________________

Date __________________
 

Parent Signature if under 18yrs__________________________Print ___________________

Date_____________
 
 

Please Send To: Anne Fortnum 22,Warwick Street, Daventry, Northants, NN11 4AL

Home