sports leisure arena in kenya
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MEMBERSHIP APPLICATION FORM WADI DEGLA INVESTMENTS LIMITED
PRINCIPLE MEMBER DATA Full Names: Date of Birth:
D
M
Y
D
M
Y
ID/Passport No: PIN No: Marital Status: No. of Children: Postal Address: Code: City/Town: Home Phone: Mobile No: Office No: Email Address: Nationality: Employer: Position: Sports Practiced: Other club memberships: Have you ever been expelled from any private membership club?
YES
NO
If so please provide details:
Other Interests:
SPOUSE DATA Full Names: Date of Birth: ID/Passport No: PIN No: Marital Status: No. of Children: Postal Address: Code: City/Town: Home Phone: Mobile No: Office No: Email Address: Nationality: Employer: Position: Sports Practiced: Other club memberships: Other Interests: 3
INTRODUCTION Introduced by
Membership No.
Name
Signature
CHILDREN 1.)
Full Names: Date of Birth:
D
M
Y
D
M
Y
D
M
Y
Sports Practiced: Other Interests:
2.)
Full Names: Date of Birth:
Sports Practiced: Other Interests:
3.)
Full Names: Date of Birth:
Sports Practiced: Other Interests:
NEXT OF KIN Full Names: Mobile No: Relationship:
BENEFICIARY Full Names: Mobile No: Relationship:
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ADDITIONAL CHILDREN 4.)
Full Names: Date of Birth:
D
M
Y
D
M
Y
D
M
Y
Sports Practiced: Other Interests:
5.)
Full Names: Date of Birth:
Sports Practiced: Other Interests:
6.)
Full Names: Date of Birth:
Sports Practiced: Other Interests:
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MEDICAL INFORMATION PRINCIPAL MEMBER: Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any):
SPOUSE: Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any):
CHILDREN: 1.) Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any):
2.) Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any):
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3.) Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any): 4.) Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any): 5.) Full Names: Pre-existing conditions: Allergies: Preferred Doctor/Family Doctor: Medical Insurance (if any):
NANNY APPLICATION FORM (Optional) Full Names: Date of Birth: ID/Passport No: Postal Address: Code: City/Town: Mobile No: Allergies:
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D
M
Y
AFFIX PHOTOS HERE
Name: Name: Name: Name:
Name: Name: Name: Name:
Name: Name: Name: Name:
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CHECKLIST
ID/PASSPORT COPY PIN CERTIFICATE COPY (principle member and spouse)
PASSPORT SIZE PHOTOS (2 copies each)
COPIES OF BIRTH CERTIFICATES (for the children) MEDICAL INSURANCE CARDS (copies-if any)
I/We hereby apply for membership of Wadi Degla Club. I/We confirm that all information provided on the form is accurate and that I/We are Citizen(s) of good standing. I/We know of no reason why the club management should not consider the application.
I/We accept that the application is subject to the scrutiny by the Club and their decision is final. I/We also accept that should the application be successful, I/We agree to abide by the constitution and by-laws of Wadi Degla Club. I/We understand that if the application is successful and the membership fee paid (whether in part or in full) it is not refundable should I/We choose not to go ahead with the application process.
Principle Members Signature: ………………………………………………….……………………………………. Date: ……………………………………………… Spouse’s Signature: …………………………………………………………………..……………………………………. Date: ……………………………………………….
FOR OFFICIAL USE ONLY Payment Details: Membership fees (Kshs) Paid by Cash/Cheque/EFT
Annual Maintenance Fee for year :
Membership Fee paid by:
Point System Evaluation No: Approved:
Yes
No
The Form has been checked and all the elements verified: …………………………………………………………………………………… ……………………………………………………………………………………………… Signed by Club Manager Date
Membership Registration Number Assigned: …………………………………………..………………………………………………………………………
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Please insert copies of relevant documents in the pocket
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Fun Fitness Health Lifestyle Culture Family
Fill The Application Form & Send It To Wadi Degla Kenya
Tel 1 : +254 701 950 549 Tel 2 : +254 788 888 818 1st Floor Piedmont Plaza, Ngong Road P.O.Box 41973-00100 - Nairobi, Kenya www.wadidegla.co.ke