Full Name__________________________________________________
Address___________________________________________________
Tel number___________________
E mail_____________________________________________________
Membership type (please circle)
Adult £5 Family £10* Unwaged £2.50 Under 18 £1
*For Family membership please state all names and ages of children under 18
Family membership is for 2 adults and their children up to 18 years old
_________________________________________________________
Please print this form and send it to the CCC Membership Secretary
9 Ashgate Avenue
Chesterfield
S40 1JB
N.B. These details will be stored on Computer