THJFC 12 13 JM embership and Consent Form v1 pwp by aYkc51

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									CLUB SECRETARY:
Peter Culley
Tel: 07980 732 881                                                               J
      TULSE HILL JUNIOR FOOTBALL CLUB: SEASON 2012-2013
          REGISTRATION AND PARENT CONSENT FORM
Please Complete in BLOCK capitals:

1.      Details of football activity: Training Sessions, Summer Tournaments, Organised
        League, Cup and Friendly Football Matches.
2.      From:             1st July 2012          To:          30th June 2013
3.      I agree to                                                         (Child’s Full Name)
        Taking part in the activities detailed above and I acknowledge the need for my child to
        behave responsibly.

4.      Player’s Home Address
                                                                     Postcode
        Player’s Home Nr.                                  Player’s Date of Birth
        Player’s Mobile Nr.
        Player’s Email Address

5.      Ethnic Origin          White                   Chinese
        Please tick one.       Black African           Black Caribbean
                               Black Other             Pakistani
                               Indian                  Other (please specify)

6.      Player’s Education Details (if applicable)
        School/College
        Address
                                                                      Postcode

7.      Player’s Medical Information
7a.     Are there any conditions which require medical treatment,                YES   or NO
        including medication? Please tick one only.
        If YES, Please give brief details

7b.     Are there any special dietary requirements? Please tick one only.        YES   or NO
        If YES, Please give brief details

7c.     Please state the type of pain/flu relief that may be given to your child if necessary.


7d.     Is your child allergic to any medication, food, detergent, etc?          YES   or NO
        Please tick one only.
        If YES, Please give brief details

7e.     When did your child last have a tetanus injection?
7d095d9d-613a-46d1-8d55-C2bbb0f85a69.Doc                                                Page 1 of 2
Revision date: May 2012
CLUB SECRETARY:
Peter Culley
Tel: 07980 732 881                                                          J
      TULSE HILL JUNIOR FOOTBALL CLUB: SEASON 2012-2013
          REGISTRATION AND PARENT CONSENT FORM
Please Complete in BLOCK capitals:

8.      EMERGENCY CONTACT DETAILS
8a.     1st Emergency Contact Details
        First Name                            Surname
        Address
                                                                 Postcode
        Contact Nr. 1:                             Contact Nr. 2:

8b.     2nd Emergency Contact Details
        First Name                            Surname
        Address
                                                                 Postcode
        Contact Nr. 1:                             Contact Nr. 2:

8c.     Family Doctor Contact Details
        Name                                  Telephone Number
        Address
                                                                Postcode

9.      Parental Consent
        In the event that my child is injured whilst playing football/travelling to and from
        football events and I cannot be contacted on the above numbers, I hereby give my
        consent for my child to receive medical attention. I also hereby give my consent for
        my child to receive any emergency dental, medical or surgical treatment (including
        anaesthetic or blood transfusion) as considered necessary by the medical authorities
        present.
        I further hereby give my consent for photographs of my child to be shown on the
        official Tulse Hill website and/or OurKidsSports website.
        I confirm that I have read and understood the latest Club Codes of Conduct and Club
        Rules and that I will abide by them, that I will encourage my child(ren) to abide by
        them and that I will encourage any other family members or friends who attend any
        club activity to abide by them.

        Signed                                                      Dated
        Full Name

10.     Codes of Conduct (Player to Sign)
        I confirm that I have read and understood the latest Club Codes of Conduct and Club
        Rules and that I will abide by them.

     Signed                                                  Dated
     Full Name
Should any of the above details change during the season please inform the Team
Manager, the Coach or the Club Secretary as soon as possible.
7d095d9d-613a-46d1-8d55-C2bbb0f85a69.Doc                                           Page 2 of 2
Revision date: May 2012

								
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