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Gloucester Rugby Youth Talent Squad

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									                            Gloucester Girls Rugby
                  Development Programme Application Form
                                     with
   Medical Details, Hospital Treatment Authorisation & Photo Consent 2009/10
    This application form registers your child to train and play rugby for Gloucester Girls Rugby Charitable
    Trust Fund. Each player must complete this form regardless of status (i.e. new applicant/previous
    applicant). The form must be signed by a parent/guardian if the applicant is Under 18

FORNAMES:                                                                SURNAME:

ADDRESS Line 1:                                                          DATE OF BIRTH:            /     /         AGE GROUP
                                                                         (please circle as of age 1st September)
                                                                         U12          U15        U18                    Over 18
                                                                         SCHOOL/COLLEGE/UNIVERSITY:
ADDRESS Line 2:
                                                                         Have they a female rugby team:               Y/N
ADDRESS Line 3:                                                          Playing Position:

ADDRESS Line 4:

ADDRESS Line 5:                                                          Club:                               Coach:

Post Code:                                                               Coach Telephone:

Tel (Home):                                                              Tel (Mobile):

E-MAIL Address (player*):                                                E-MAIL Address (parent/Guardian*)

                                                                         *U12/15/18 only
Mailshots – I am happy to receive news letters and updates from the      Nb: The charity or its staff will not distribute your
charity and development programme? Y/N                                   information to any 3rd party organisation.
      Emergency Contact Name                      Relationship                                 Number
1)
2)
3)
Medical History (asthma, diabetes, epilepsy. Please include              Regular Medication Prescribed:
serious/long term injury).

Do you give permission for First Aid to be administered in your
absence? (Circle)*                                                                     Yes        No
In the event of you not being available do you give permission for
hospital treatment? (Circle)*                                                          Yes        No
Do you agree to authorise the lead coach or team manager of the
squad to give consent on my behalf for an anaesthetic to be given on                   Yes        No
the advice of a medical practitioner? (Circle)*
Do you consent to the photographing/ skill videoing and publication of
images of your daughter in line with the RFU Child Protection                          Yes        No
Procedures and Best Practice? (Circle)
Any other Comments you wish to make of significance:

Parent/Guardian Signature:                                Please print name:

Date:
Please post to GGRCTF, C/O Saddleford, Station Road, Lambourn, West Berkshire, RG17 8PH
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