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					Stafford Ladies Hockey Club
Senior Member Registration Form
Personal Information – Please provide us with accurate contact numbers and email
addresses in order that we can update our records

Your subscription ensures that you are covered by Insurance, allows access to
training and gives you associate membership to Stafford Cricket & Hockey Club

Name

Address

Telephone                                                         Mobile

Email

Emergency Contact Details (To be contacted only in case of an emergency)

Name

Number                                                            Relationship

Medical Information

Please detail any important medical information that our
coaches/team captains should be aware of (e.g. Epilepsy,
asthma, diabetes, etc.)

Disability

* Do you consider yourself to have a disability?                                                            Yes
* Delete as applicable


If yes, what is the                                 Visual Impairment                                       Yes
Nature of your                                      Physical Disability                                     Yes
disability?                                         Multiple Disability                                     Yes
                                                    Hearing Impairment                                      Yes
                                                    Learning Disability                                     Yes
                                                    Other Disability? (Please specify)

The Disability Discrimination Act 1995 defines a disabled person as anyone with a “physical or mental impairment, which has a
substantial and long term adverse effect on his or her ability to carry out normal day to day activities”.
By signing and returning this form, you consent to Stafford Ladies Hockey Club using and
keeping information about you, provided by you or third parties.

Signature

Name

Date

Data Protection Act 1998

The information given on this form is likely to be processed by computer. It will only be used for essential purposes (such as medical and
personal information) by Captains and Committee members of Stafford Ladies Hockey Club. If you join the Club the information you have
provided will be transferred to our computerised information system.




* I enclose payment for / I have paid directly to the club bank account:
* Delete as applicable           Bank details can be obtaining from the treasurer.
Bank details:
Account Name                     xxxxxxxxx
Sort Code                        xxxxxxxxx
Account Number                   xxxxxxxxx

                                                     Senior membership £60
                                                     Student Membership£35
                                                     Non-Playing Membership £35
                                                     Goalkeeper with own kit £30


PLEASE NOW RETURN THIS FORM WITH YOUR SUBSCRIPTIONS TO:

Christine Weetman
7 Bridle Road
Stafford
ST17 0QD

OR, IF YOU HAVE PAID DIRECTLY INTO THE BANK, EMAIL THE FORM TO:

christineweetman@hotmail.co.uk
act numbers and email


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icket & Hockey Club




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posted:9/24/2011
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