Finn Valley Athletic Club
(Founded 1971)
Milbrae, Stranorlar, Co Donegal
Tel No: (074)9175350
Email: finnvalley1@gmail.com
Application for Membership Form 2015-2016
Please complete in full & return to reception with the relevant fee. Membership not
effective until full fee is received.
Name: __________________________________________________________
Address: ________________________________________________________
________________________________________________________________
Tel/Mobile No: __________________________________________________
Email Address: __________________________________________________
D.O.B: ________________________
Category:
JUVENILE MEMBERSHIP
€40
SENIOR MEMBERSHIP
€100
FAMILY MEMBERSHIP
€125
Family Members
1st Name ____________________________ D.O.B. ________________
2nd Name ____________________________D.O.B. ________________
3rd Name ____________________________ D.O.B. ________________
4th Name ____________________________ D.O.B. ________________
5th Name ____________________________ D.O.B ________________
Details of any Health Problems: ___________________________________
________________________________________________________________
Signed: ......................................................
For office use only:
Membership Proposed by: __________________________________________
Seconded by: ____________________________________________________
Amount Received: _____________________
Received by: __________________________ Date: _____________________
Membership No: ____________________ Expiry Date: ___________________
Finn Valley Athletic Club
Cardiac Screening Questionnaire
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Tel/No: ____________________________________________________________________
D.O.B. ___________________________
Parent/Guardian: ____________________________________________________________
Pleas tick where appropriate
Yes
No
Have you any previous history of heart disease?
Is there any family history of Sudden Cardiac Death in close relatives
(brothers, sisters, parents) under 50 years of age?
Do you suffer from or have you suffered with chest pains when exercising?
Do you suffer from or have you suffered with breathlessness when exercising?
Do you suffer from or have you suffered with dizziness when exercising?
Do you suffer from or have you suffered with palpitations (a very fast or
skipped heart beat) when exercising?
PLEASE NOTE:
1.
If you are between 14-16 years old you should complete this questionnaire with the
assistance of your parent(s)/guardian
2.
If you reply ‘yes’ to any of the questions above you should make an
appointment to see your Family Doctor. Please bring the completed questionnaire
to the consultation.
3.
Your Family Doctor may perform an examination which might include an
Electrocardiogram (ECG) or ‘Heart Tracing’.
4.
Your Family Doctor may decide to refer you to see a Cardiologist or ‘Heart Specialist’.
REMEMBER: If you reply ‘yes’ to any of the questions above you should make an appointment
to see your Family Doctor.