Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Club membership form template by lmUp4Z0f

VIEWS: 54 PAGES: 3

									                                                                                                                    Peter Carter
                                                                                                                    Youth Membership Secretary
                                                                                                                    Carters, Ulting Road
                                                                                                                    Hatfield Peverel
                                                                                                                    Chelmsford, Essex
                                                                                                                    CM1 2PP
                                                                                                                    07785 328104
                                                                                                                    youth_membership@chelmsfordhc.org.uk


                                                     CHELMSFORD HOCKEY CLUB
                                                                   http://www.chelmsfordhc.org.uk
                                                                  http://facebook.com/ChelmsfordHC
                                          Youth Membership Subscriptions and Training Fees, 2011/2012 Season

All current and prospective members of Chelmsford Hockey Club are required to complete this registration form and return it
with payment. All details will be kept in a secure database with access restricted to authorised club officers only.

PARENT CONTACT INFORMATION

 TITLE                 Mr/Mrs/Miss/Ms (Please circle)                                                                                    2011/12
 FULL NAME                                                                                                                             MEMBERSHIP
 ADDRESS 1

 ADDRESS 2                                                                    HOME PHONE                                             YOUTH MEMBERS,
                                                                                                                                        FOR WHOM A
 TOWN                                                                         MOBILE PHONE
                                                                                                                                     SIGNED PARENTAL
 POST CODE                                                                    EMAIL                                                  CONSENT FORM IS
                                                                                                                                    NOT RECEIVED WILL
                                                                                                                                     NOT BE ALLOWED
YOUTH MEMBER INFORMATION                                                                                                              TO TAKE PART IN
                                                                                                                                       TRAINING OR
 FULL NAME                                                                                                                                MATCHES

 ADDRESS 1                                                                    DATE OF BIRTH                                          IF TRAINING FEES
                                                                                                                                      REMAIN UNPAID
 ADDRESS 2                                                                    HOME PHONE
                                                                                                                                      AFTER THE DUE
 TOWN                                                                         MOBILE PHONE                                            DATE, A YOUTH
                                                                                                                                      MEMBER MAY BE
 POST CODE                                                                    EMAIL                                                       REFUSED
                                                                                                                                     PARTICIPATION IN
                                                                                                                                       TRAINING AND
                                                                                                                                         MATCHES
YOUTH SUBSCRIPTIONS AND TRAINING FEES
                      Paid by      30 Sep           31 Oct Half     Training fee
                                                               30 Nov                  Training Fee
                                                           Season   (half Season)      (Full season)
 Years 9 – 13               £43.00     £51.00    £54.00    £29.00   None               None
 Years 5 – 8                £20.00     £25.00    £30.00    £15.00   £24                £42
 Up to & including Year 4   £16.00     £18.00    £21.00    £13.00   £24                £42
 Adult Social               £10.00     £10.00    N/A       N/A      N/A                N/A
Half Season training fees are due latest 31Oct 2011 and 31Jan 2012 – Full Season training fees are due 31 Oct 2011.

MEDICAL INFORMATION & CONSENT
(To be completed by PARENT or GUARDIAN if under 18)

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                                                  RELATIONSHIP                                MOBILE PHONE

 DOCTORS NAME                                                 SURGERY                                     PHONE

 As far as you are aware, are you allergic to any drugs? (Please state)

 Are you taking any regular medication? If so, for what reason?

 Do you have any long term illnesses or injuries?


 Declaration: I consider myself (my son/daughter)* 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 my son/daughter)* for the team
 managers/coaches appointed by Chelmsford Hockey Club to obtain emergency medical treatment on my behalf.

 SIGNED                                                       DATE                                        (RELATIONSHIP)



PLEASE TURN OVER;
2011- 2012 Youth Membership & Consent form
SECTION 5: UNDER 18 MEMBER CONSENT (**TO BE COMPLETED BY PARENT/GUARDIAN**)
It is a requirement of club policy that parental consent is provided for participation, transportation and photography. The Chelmsford Hockey Club members Code of
Conduct and Safeguarding and Protecting Young People in Hockey Policy are available in the club handbook.

Please delete as appropriate where indicated by a * then sign and date at the bottom.

TRANSPORTATION: I consent to my son/daughter* travelling to venues for matches and training by transport provided by the club which may include travelling in other
players private cars.

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 ANOTHER HC. Such images shall only be
used for publicity/training purposes in accordance with the Chelmsford Hockey Club 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 i.e. local newspapers, local magazines, other promotional articles (inc. flyers)
and the club’s website.

  SIGNED                                                        DATE                                                     RELATIONSHIP




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.

England Hockey requests this data from clubs as part of the annual affiliation process and completing this data accurately enables the club to give an accurate picture to
England Hockey on our membership.

PLEASE TICK THE BOX THAT BEST DESCRIBES YOUR ETHNICITY

                ETHNICITY OF CLUB MEMBERS
                                                            TICK BOX                                                                   TICK 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

PLEASE TICK TO INDICATE ANY LEARNING OR PHYSICAL DISABILITIES

                                         DISABILITY
                                                                                    TICK BOX
Deaf
Visually impaired
Hearing impaired
Physical disability
Learning disability
Multiple disability

Please add any additional relevant information:



COACHES/MANAGERS INFORMATION
To ensure that Chelmsford Hockey Club has the correct contact details for your child and you, please complete/amend
the information requested on the next sheet. This sheet is retained by your child’s coach and manager and the
information is used in the event of an accident or incident.

Please return all forms duly completed and signed to Peter Carter at the address at the header of this form with the
appropriate payment.

 PLEASE COMPLETE THE CONSENT FORM ATTACHED, WITHOUT THIS FORM YOUR CHILD CANNOT ATTEND
                                        TRAINING OR PLAY IN MATCHES.
2011- 2012 Youth Membership & Consent form
                                       CHELMSFORD HOCKEY CLUB
                       YOUTH SECTION CONSENT FORM 2011/2012 SEASON
As with all sports, playing hockey carries a small risk of injury. It is strongly recommended that all players wear shin pads and
gum shields for training and for matches. Parents should be aware that in the event of the youth member choosing not to
wear this protection Chelmsford Hockey Club will not be held responsible for any injury sustained as a result. Child
Protection Act; all coaches and managers have been made aware of the English Hockey Guidelines regarding Child Protection. If you
would like any further details or information on the policy as implemented within Chelmsford Hockey Club please contact our Child
Protection Officer – Chris Randall. All sessions run by the Youth Section shall be run, wherever possible, under the guidance of
qualified Hockey England Ltd coaches.
Please complete/amend all parts of this form, sign and return to Peter Carter at the address on the membership Form.

YOUTH/STUDENT MEMBER DETAILS (Fields marked *at parents discretion) Membership No:
Name                                            DOB
Active Email*
School/College                                  Mobile*

PARENT CONTACT DETAILS
Parent/Guardian
Address



Post Code
Tel. Number
Mobile Number
Active email

EMERGENCY CONTACTS
Name 1                                                                      Phone
Name 2                                                                      Phone
Doctor                                                                      Phone
Surgery
ANY KNOWN MEDICAL OR OTHER CONDITIONS (Including any current medication or known allergies)
(If None, State ’None’)

   Most of the communication with members other than at training is by e-mail. Chelmsford Hockey Club undertakes to hold the above information
confidentially, and will only use the information for CHC related activities. In the event that Parents may choose not to give the mobile number or email
                                  address of the youth member, please ensure that the Parent’s contact details are clear.

CONSENT;
     I agree to my daughter/son taking part in the activities of the Chelmsford Hockey Club, and accept that Chelmsford Hockey
      Club should hold the contact details of the above mentioned Youth Member which will be held confidentially and used only
      for Chelmsford Hockey Club purposes.
     I confirm that to the best of my knowledge my daughter /son does not suffer from any medical condition other than those
      listed above.
     I consent to my daughter/son travelling by any form of public transport, mini-bus or by a motor vehicle (fitted with seat belts)
      driven by a Chelmsford Hockey Club Official, or any other parent/guardian attending an event in which the Club is
      participating in.
     In the event that I as a parent/guardian am called upon to assist with transporting children other than my own I confirm that
      my vehicle will be covered by insurance and fitted with seat belts that comply with the appropriate British Standard. I shall
      ensure that the seat belts are worn at all times.
     I authorise the leader of the party or any Club official accompanying the party who may be present to consent to such
      medical treatment (including inoculations blood transfusions or surgery) which in the opinion of a qualified medical
      practitioner may be necessary during any time when my daughter/son is with the Chelmsford Hockey Club and away from
      direct parental control and discretion.
     I give permission for the above mentioned Youth Member to be included in photographs related to Chelmsford Hockey Club.




SIGNED:………………………………………………..                                                                            PARENT/GUARDIAN


NAME ………………………………………………….                                                                    DATE……………………………...
Please PRINT name in Block Capitals

2011- 2012 Youth Membership & Consent form

								
To top