Club Membership Form

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					                                         Club Membership Form
Contact details
Full name
Home Address
                                                      Post code
Home number                                           Date of birth
Mobile number                                         Email address

Ethnic Origin     White             Chinese           Asian           Black African     Black Other
(please tick)     Black Caribbean             Other

Emergency Contact details
First Name                                            Surname
Relation to above                                     Emergency contact number
In the event that the above person cannot be reached, for all junior players please give two extra
emergency contact names and numbers
Name                                                  Emergency contact number
Name                                                  Emergency contact number
Parental consent (for all players under 18)
In the event that my son/daughter is injured whilst playing football/travelling to and from football
events and I cannot be contacted on the above number, I hereby give my consent for my child to
receive medical attention.
Signed                                                Date
I hereby consent for my child to be photographed on the understanding that the picture will only be
used by the Club for publicity or sponsorship
Signed                                                Date

Any medical ailments or conditions we need to be aware of. [This includes any medication taken]

I agree to be bound by and observe the Club Rules and The Rules and Regulations of The Football
Association Limited and County Football Association, and all competitions in which the Club
I consent to disclosure by Leicestershire and Rutland County Football Association
I have read the Club Rules and Code of Conduct and agreed to abide by them as a member of
Market Bosworth Football Club

Signed (player/member)                                                Date

Signed (parent/guardian)                                              Date

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