JOGSCOTLAND MEMBERSHIP APPLICATION If you would like to become a jogscotland member, please complete this form. If you would like to renew your existing membership, please contact the jogscotland team at firstname.lastname@example.org Title*Please selectMrMissMrsMsDrRevFirst Name*Last Name*Street address*Address Line 2City/Town*CountyPostcode*CountryDate of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mobile phone numberHome phone numberWork phone numberEmail address* Enter Email Confirm Email RegionPlease select regionAberdeenshireAngusArgyll and ButeCity of DundeeCity of GlasgowDumfries and GallowayEast DunbartonshireEast RenfrewshireFifeInverclydeMorayNorth LanarkshirePerthshire and KinrossScottish BordersSouth AyrshireStirlingWest DunbartonshireCity of AberdeenCity of EdinburghClackmannanEast AyrshireEast LothainFalkirkHighlandsMidlothianNorth AyrshireOrkney IslesRenfrewshireShetlandSouth LanarkshireWest LothianWestern IslesGroupFirst ChoiceSecond ChoiceThird ChoiceLevel of groupPlease selectBeginnerIntermediateAdvancedMixedGenderMaleFemaleEthnic originPlease selectWhite – Scottish, other British, Irish, OtherMixed – Any mixed backgroundAsian, Asian Scottish or Asian British – Indian, Pakistani. Bangladeshi, Chinese, any otherOther Ethnic Background – Any other ethnic backgroundI prefer not to sayDisabilityPlease indicate whether you regard yourself as having a disability.Please selectYesNoNature of disabilityPlease indicate the nature of your disability: Physical Sensory Learning If "Other", please specify how you found out about jogscotlandLets keep in touch As one of our members, jogscotland will email you with updates, from time to time, about offers and news relevant to jogging. Please tick this box if you'd rather not receive such email. Research If you consent to participate in jogscotland member activity and health research please tick this box.