Personal Details - DOC 9 by HC120913204333

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									                     Stevenage Hockey Club Member Registration & Participation 2012/2013




                                           SHC Ditchmore Lane, Stevenage, Hertfordshire, SG1
                                                       www.stevenagehc.co.uk
                                                                                                            _______________________

All prospective and current members of Stevenage Hockey Club are required to complete this registration form for every
season and return it before the start of league season. All details will be kept in a secure database with access restricted to authorised
club officers only. This data will be used to keep you up to date with any club news.

The club’s annual membership fee (subs) MUST be paid either:
        In Full by 31st October 2012
        Or by committing to one of the below options by Standing Order (not applicable to non playing members)

Please select and confirm which of the following payment methods you agree to make;
I confirm and agree to pay my SHC membership subscription fee by the following method and date.
1) Direct Debit option of £18 per month over August, September, October, November and December 2012. YES /NO
2) Direct Debit option of £30 in September then £20 in October, November and December 2012.          YES /NO
3) A Full Payment of £90.00 between now and 1st October 2012.                                        YES /NO

Direct Debit Forms are available on the club website or you can set up a standing order:
STEVENAGE HOCKEY CLUB, Barclays Bank Plc, Sort code: 20 – 41 – 12, Account number: 60110205

SECTION 1: MEMBER CONTACT INFORMATION (Delete as appropriate)

Please Choose:    Playing Adult / Playing Junior (under 18) / Playing Full Time Student/ Non Playing Social Member

 TITLE                  Mr/Mrs/Miss/Ms (delete as appropriate)

 FULL NAME
 ADDRESS 1                                                        DATE OF BIRTH
 ADDRESS 2                                                        HOME PHONE
 TOWN                                                              MOBILE PHONE
 POST CODE                                                         EMAIL
 Squad No.

SECTION 2: UNDER 18 MEMBER CONSENT (**TO BE READ, COMPLETED & SIGNED BY PARENT/GUARDIAN**)

It is a requirement of club policy that parental consent is provided for participation, transportation and photography. The SHC members
Code of Conduct and Safeguarding and Protecting Young People in Hockey Policy are available on the club website.
Please delete as appropriate where indicated by a * then sign and date at the bottom.

Transportation: I consent and agree that if my son/daughter* travels to venues for matches and/or training in other players/members
private cars, Stevenage Hockey Club does not accept any liability.

Photography: In some environments, particularly adult competition it is impossible to control photography by external parties, however,
I am aware that there maybe times that photographs and/or footage maybe taken during matches and training sessions by approved
agents and/or officers of SHC Such images shall only be used for publicity/training purposes in accordance with the SHC Safeguarding and
Protecting Young People in Hockey Policy and Photography Policy and give consent for my son/ daughter to feature in such photos/
images. I hereby only grant approved agents the right to use the images resulting from the photo/film shoots. This includes any
reproductions or adaptations of the images for all general purposes ie local newspapers, local magazines, other promotional articles (inc.
flyers) and the club’s website.

 SIGNED By
                                                   DATE                                         RELATIONSHIP
 Parent/Guardian



Please turn over.
SECTION 3: ETHNICITY & DISABILITY

Whilst it is not compulsory for the following sections to be completed, the paragraph below explains why this personal information is
considered to be important.

Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have existed within sport
particularly in relation to gender, race and disability. Sport England and England Hockey are committed to promoting and developing
sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By
monitoring the profile of people in sports clubs, national governing bodies of sport and Sport England can identify any issues relating to
under representation of different groups and can develop strategies to ensure that all people have the opportunity in the future to develop
and progress in sport.
Please tick the box which best describes your ethnicity;

                                                  MARK BOX                                                      MARK BOX
White British                                                Asian or Asian British – Pakistani
White Irish                                                  Asian or Asian British – Bangladeshi
White Other                                                  Asian or Asian British – Other
Mixed – White and Black Caribbean                            Black or Black British – Caribbean
Mixed – White and Black African                              Black or Black British – African
Mixed – White and Asian                                      Black or Black British – Other
Mixed – Other                                                Chinese
Asian or Asian British – Indian                              Other Ethnic Group

SECTION 3: MEDICAL INFORMATION & CONSENT – playing members
In case of emergency and as part of the clubs responsibility to its membership, ALL club members are required to complete this medical
information form as accurately as possible. Details will be held securely with access restricted to authorised club officers only.

 NEXT OF KIN/EMERGENCY                                                                                   MOBILE
                                                                     RELATIONSHIP
 CONTACT                                                                                                 PHONE
 Please state any medical condition that our coaches/team captains should be aware of (e.g. epilepsy, asthma, diabetes, etc.):




Self Declaration (delete yes/no as appropriate)


        Playing members only - I consider myself to be physically fit and capable of full participation and agree to notify the club of
         any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission for the team
         managers/coaches/captains/vice captains/umpires appointed by Stevenage HC to obtain emergency medical treatment on my
         behalf.
                                                                                                  YES /NO


        All members - I have a valid Driving License and minimum third party insurance             YES /NO

        All members - Are you a person known to any social services department as being an actual or potential risk to children?
                                                                                             YES /NO

        All members - Have you had a disciplinary sanction (from sports or other organisations governing body) relating to child abuse?
                                                                                                YES /NO

I confirm that the details disclosed on this form are to the best of my knowledge correct and accurate. I understand that false information
or omission could lead to termination of membership.

If you are completing and returning this form electronically via e-mail – please print your name in the signature box.
This will act as and be your signature and declaration to the details and information you have provided.
Your completed registration form and the email it is attached to will be stored securely until September 31st 2013

 SIGNED                                                               DATE



Please return the form to Hilary Siddall, Membership Secretary membership@stevenagehc.co.uk or give to your captain to pass on.




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