DCU Staff Membership Application

Name *

Email Address *

Membership type *

Individual

Couple

Family

Phone number

Staff Number *

Department *

Contract end date *

If permanent/COID please note this.

Frequency of salary *

Weekly

Monthly

Authorisation of deduction from payroll *

Yes - contract must be longer than twelve months

No - if you choose no you can log into your online account to make the payment via credit card. Please wait for a confirmation email for when this payment is available.

PLEASE NOTE You must be FULL TIME/REGULAR hours to pay via payroll. If you cease to be paid on DCU/CR&D payrolls the balance of 12 months must be settled immediately. Payment will be in line with your contract end date. All staff memberships must be for the period of 12 months unless otherwise agreed. Any special requirements or cancellations requests must be submitted to karen.conroy@dcu.ie one month in advance.

Do you (or your family members) have any injuries/illnesses that we should be aware of? *

If none please write none, if yes, please describe

Emergency Contact Name and Number *

I have read and agree to the health questionnaire *

Yes

Health Statement: I fully understand the active nature of the programme and the risks associated with physical exercise and use of pool & spa facilities. I accept responsibility for my health and well-being on the voluntary exercise programme and related tests I am about to undertake. I understand no responsibility will be assumed by the leaders of the programme / the instructors of University Sports Complex arising from any accident, injury or loss sustained by me as a result of activities at or present in University Sports Complex. I understand that I am advised to undertake the complimentary personal training session / gym induction program provided by DCU Sport before using the fitness centre / undertaking an exercise regime. I acknowledge that I am physically fit and free from any illnesses that may be aggravated by performing exercise. I understand that medical clearance may be required by DCU Sport if I develop an illness or injury during the term of my membership.

I have read and agree to the terms and conditions. *

Yes

Membership terms and conditions are available at http://www.dcu.ie/dcusport/terms.shtml

Marketing Options - Do you agree to receive emails about programmes or events offered at DCU Sport? (Does not refer to membership related emails)

Yes

Other comments

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