Please complete this form and submit to register with the club 

Member Details

Name:
Date of birth
Squad
Home Phone
Mobile Phone
This should be the parents mobile number if the Member is Under 18
Email address
This should be the parents email address if the Member is Under 18
Address

Medical Information

Medical notes
Please detail any important medical information that our coaches/welfare officer should be aware of (e.g epilepsy, asthma, diabetes, etc.)
Do you consider yourself to have a disability?
Yes
No
If yes, what is the nature of your disability?
Please also advise if there are any special measures we can use to assist you.

Photo Consent

Please indicate if you are happy for you/your child to be photographed/videod:
Yes
No
Digital images may be used during training and matches for promotion, publicity and analysis purposes. These images may be used on the Club website, in the local press and on other media such as posters.

Emergency contact details

Contact name
Contact number

Declaration

I wish to register for the 2011-12 season
Yes please
By submitting this form I agree to the above named member taking part in the activities of the club. I understand that I will be kept informed of these activities - for example timing and transport details where appropriate.I understand that in the event of any injury or illness all reasonable steps will be taken to contact the emergency contact supplied, and to deal with that injury/illness appropriately. Parents of Junior Members: I am aware that it is my responsibility to ensure that my child is collected promptly at the end of their session time as at this time they will cease to be under the supervision of Club coaches. If any of these details change during the season, I will advise the Club.
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