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Contact details |
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Name
(please provide additional family information below) |
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Postal
address |
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Contact
telephone number |
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Contact
email address |
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About you (this section is optional but it will
help us to understand more about our members – information provided by members
will be collated and used at a collective level and no individual will be
identified as a result) |
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Are
you registered disabled? |
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Do
you have an illness or disability, which requires you to ride an adapted
motorcycle or trike? |
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Do
you belong to a motorcycle club? |
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Do
you ride a motorcycle or trike? |
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Have
you had to give up riding due to ill health? |
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Data Protection |
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Can
we use your details to contact you about news and events from MAD Scotland? |
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Additional Family Members |
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Second
adult name (if applicable) |
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Number
of children under the age of 16 |
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Please
provide date(s) of birth for each child under the age of 16 |
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Does
your family membership application include a child over the age of 16 who is
still resident with your or you are their designated carer |
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If
yes to above please provide date(s) of birth |
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About your family (this section is optional but
it will help us to understand more about our members – information provided
by members will be collated and used at a collective level and no individual
will be identified as a result) |
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Is
anyone in your household registered disabled? |
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Does
anyone in your household have an illness or disability, which requires them to
ride an adapted motorcycle or trike or requires support to ride pillion? |
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Does
anyone else in your household ride a motorcycle or trike? |
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Has
anyone else in your household had to give up riding due to ill health? |
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Membership |
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Registration
for family membership is £15.00 which entitles you to one year’s membership.
As part of your registration, you’ll be sent two membership patches. Would
you like to purchase more – if yes please state how many and include the appropriate
fee with your registration (patches are £3.50 each) |
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I
the undersigned agree that I support the aim of MAD Scotland by raising funds
directly and through community involvement for freedom of mobility for all
disabled persons in Scotland. |
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Signed |
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Date |
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