wdfc membership form - Worcestershire Disability Football Club

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					                    Worcestershire Disability Football Club
                                               REGISTRATION FORM

Full Name of Applicant...................................................................Gender(M/F)……………………

Address……………………………………………………………………………………………….

........................................................................PostCode…………………………………………

Date of Birth……………………Age Next............                                            Telephone No………......................

Parents Mobile Number. …………………………….Players Mobile…………..................

Alternative Contact Number. ………………………….Name of Contact…………………….

Your Contact EMAIL............................................ Favoured Playing position………...................

Team you last played for....................................... School(under 18 only)……….…………........

Membership Type                        PLAYER                     COACH                     ASSOCIATE (circle one)

Coaches Only: What FA certificates do you hold?.......................................................................................................

Date(s) gained:………………………………………………………………………………………………….

PARENT/GUARDIAN/CARER. PLEASE COMPLETE THE FOLLOWING (delete as appropriate)

Has the player at any time received an Anti-Tetanus injection .......................................... YES/NO

If YES give approximate date.............................................................. ..............................

Is the player allergic to any medical treatment....................................................... ..... YES/NO

If YES give details....................................................................................... .................


Please state if there are any other medical details that you feel are relevant, including details of the
applicant’s disability (check eligibility rules at www.wdfc.org/gpage1.html).


…………………………………………………………………………………………………………….


Before signing please read this: I am pleased to allow and agree that the above mentioned player shall attend training and
the play of games for Worcestershire Disability Football Club, (if under 18 years, including travelling to away games on
designated transport in the care of a qualified adult(FA child safeguarding certificate and CRB checked)), as agreed within
the rule structure of the Football Association and the Club. I am aware that the full Club Rules can be found at
www.wdfc.org. In the event of an Injury I give my permission and consent to any immediate treatment deemed necessary by
a qualified physiotherapist, First Aider or General Practitioner.

I (or the applicant) confirm that I have read and understood the clubs rules and codes of conduct I promise to abide by them.

I agree to the applicant’s photo being used in promotional press releases. I understand that NO
name will accompany ANY Photo unless specifically authorized in writing and that every attempt
will be made by WDFC to ensure that only authorized and supervised photographs are taken.

Name of Parent/ Guardian/Carer/Player (if over 18)…………………………......................... Date….................................. .

Signature ……………………………... ....................... .. …Date………………

     PLEASE RETURN FORM TO: Derek Cunningham, 6 Geraldine Road, Malvern, WR14 3PA
UNDER 18 – Form MUST be signed by Parent/Guardian/Carer.

				
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posted:3/28/2013
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