Form for Consent to Travel with Child by nrj13839


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									                                         PGSOB Hockey Club - Membership Form
                                                 2010 & 2011 Season
                    Date form completed by club member:
          Membership forms to be completed by all Club members each and every year for insurance and league registration purposes.
Personal             First Name
                     Middle Name
                     Date of Birth (dd/mm/yyyy)
Telephone            Telephone - Home (include area code)
                     Telephone - Work (include area code)
                     Telephone - Mobile
Address              House Number
                     Street Name
                     Post Code
E-mail               E-mail Address
                     Other E-mail Address (if applicable)
Hockey Info          Shirt Number (if known)
                     Shirt Size                                                             Short Size
                     Jacket/ Hoody size                                                     Waist & trouser length
                     Preferred Playing Position
                     Umpire Qualification(s)                                                Coaching Qualification(s)
                     CRB Registered (& number if known)
Emergency            Name & Tel Number
Information          Relationship to Club Member:
Any known medical conditions that the Club should be aware of?

Please tick all as appropriate:

                     Active Player                      Umpire                              Vice President
                     Non-Active Player                  Coach                               Other (please specify)
                     Honorary Member                    Volunteer

I consent to any emergency medical treatment required by my child during the course of any club activity / event.
I confirm that my child is in good health, and I consider them fit to participate in any club activity/ event.
I understand that the Club may arrange for photographs to be taken of its activities, and that I consent for the Club
to use these for bona-fida promotional purposes. The Club will handle all photographs sensibly and securely.
I consent to allowing my child to travel to and from home and away matches as per the travel arrangements (car or minibus) as
organised by PGSOB HC.
The information you provide will be used to ensure the safety of all participants, and may be shared with other people and/or
organisations involved with the delivery of these activities.
By signing this form you are consenting to the Club using the information, which you have supplied, in the manner stated above.
Name of Parent / Guardian:                                                      Date:

Information required by England Hockey for club affiliation audit. Please tick as appropriate:
Ethnicity:        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                                      Asian or Asian British – Caribbean
                     Mixed – White and Black African                                        Asian or Asian British – African
                     Mixed – White and Asian                                                Asian or Asian British – Other
                     Mixed – Other                                                          Chinese
                     Asian or Asian British – Indian                                        Other Ethnic Group

Disability:          Visually Impaired                  Hearing Impaired                    Physical Disability
                     Learning Disability                Multiple Disability
Age Group:           5 to 11         12 to 16          17 to 18          19 to 21       22 to 44         45+

Committee Use Only: Annual subs paid and/or Direct Debit form completed:                                       Yes / No
Please complete all of the above relevant information and pass to Club Secretary Bruce Danbury,
to your Captain, or any member of the Committee. (Capts&Committee - please ensure all forms are passed to Club Sec).
Alternatively, email the above information to
or post to Bruce Danbury, 4 Chapel Meadow, Buckland Monachorum, Yelverton, Devon, PL20 7LR (M: 07769 970 535)

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