Registration Form

Personal Details = required

Full Name

Home Address

Home Phone

Work/Other Phone

Mobile Phone

Email Address

Alternate Email

Date of Birth

Gender

Male Female

Membership Start

When would you like your membership to start?

As Soon As Possible Specific Date

Preferred Start Date
(if applicable)

Membership Category

Please select your preferred membership category

	Category	Cost
	Junior - First Claim Under 18 - plus £23 EA fee 2026/7 Only available to people up to the age of 17.	£10.00
	Junior - Second Claim Under 18 Only available to people up to the age of 17.	£10.00
	Junior - Unaffiliated Under 18 Only available to people up to the age of 17.	£10.00
	Senior - First Claim Over 18 - plus £23 EA fee for 2026/7 Only available to people between the ages of 18 and 59 inclusive.	£20.00
	Senior - Second Claim Over 18 Only available to people between the ages of 18 and 59 inclusive.	£20.00
	Senior - Unaffiliated Over 18 Only available to people between the ages of 18 and 59 inclusive.	£20.00
	Concessionary - First Claim Members who are 60 years old or over at the start of the membership year or the date of joining. Plus £23 EA fee for 2026/7 Only available to people aged 60 or over.	£10.00
	Concessionary - Second Claim Members who are 60 years old or over at the start of the membership year or the date of joining. Only available to people aged 60 or over.	£10.00
	Concessionary - Unaffiliated Members who are 60 years old or over at the start of the membership year or the date of joining. Only available to people aged 60 or over.	£10.00

Data Protection

I understand that any personal data I provide on this site will be processed in accordance with the Terms & Conditions and Privacy Policy. I have read and agree to the Terms & Conditions (https://www.staffsmoorlands-ac.co.uk/Home/TermsAndConditions) and the Privacy Policy (https://www.staffsmoorlands-ac.co.uk/PrivacyPolicy;).

Signature

Date

Please return completed forms to: Staffordshire Moorlands AC, Birchall Playing Fields, Cheddleton Road, Leek, ST13 5RE

Use this form to send an email to another member. You may only send to one member at a time. Your registered email address will be passed on to this member but you may also include alternative contact details.

Note: Emails sent via the website are not entirely private. A copy of every email is held on the database and this can be accessed by the club officers using the Sent Emails page.

From

Alternative contact email

Another email address which the recipient can use to contact you.

Alternative contact details

Other contact details which the recipient can use to contact you e.g. phone number.

Subject

Message

Copy this message to my email address

Title

Description

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