Liss Cricket Club

Liss Cricket Club - Colts Membership Form

LISS CRICKET CLUB COLTS MEMBERSHIP FORM 2017

Welcome to Liss Cricket Club.  This Junior Membership Form should be completed by the parent or legal guardian of any player under the age of 18 and must also be signed by the player.
Please complete this form and return it to Helen Evans, Club Secretary, 7 Willow Road, Liss GU33 7EE

We will also use this information to ensure that you are kept informed about events and information concerning Liss Cricket Club.

 

Section 1 – Personal Details of the child applying for Junior Membership

Name:

 

Age:

 

Address:

 

 

 

Name of School / College:

 

 

Section 2 – Contact Details of Parent / Legal Guardian

Name:

 

Relationship to child:

(e.g. parent / legal guardian)

Address:

 

 

 

Daytime telephone number:

 

Evening telephone number:

 

E-mail:

 

 

Section 3 – Emergency Contact Details (Alternative Contact)

In the event of an incident or emergency situation where a parent, or legal guardian named above cannot be contacted, please provide details of an alternative adult who can be contacted by the club.  Please make this person aware that his or her details have been provided as a contact for the club:

Name:

 

Relationship to child:

E.g. Aunt, grandparent, neighbour etc.

Address:

 

 

Daytime telephone number:

 

Evening telephone number:

 

Section 4 - Sporting Information

Has the child played cricket before?

Yes

No

If yes, where have they played cricket?: (please indicate below)

Primary school                       

Secondary school

Special Educational Needs School

Local authority coaching session(s)

Club

County

Other (please specify)

 

 

 

Section 5 – Information about any Impairment

Please provide information about any impairment your child may have so that we can determine what reasonable adjustments may be required to support your child’s full participation in club activities.

Do you consider your child / the child in your care to have an impairment?

Yes

No

If yes, what is the nature of the impairment?

Visual impairment

              

Hearing impairment   

Physical impairment

Learning difficulty

Multiple impairments

Other (please specify):

 

 

If you have ticked yes in any box above please provide us with any additional information that will assist us to ensure your child is fully supported whilst at the club.

 

 

 

 

 

 

Section 5 – Medical Information

Name of Doctor / Surgery:

 

 

Doctor / Surgery telephone number:

 

Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, current medication, injuries etc.)

 

 

 

 

 

 

Medical consent:

?          I give my consent that in an emergency situation the club may act in my place, (in loco parentis), if the need arises for the administration of emergency first aid and / or other medical treatment which in the opinion of a qualified medical practitioner may be necessary. I also understand that in such an occurrence all reasonable steps will be taken to contact me as the relevant parent / legal guardian, or the alternative adult I have named in section 3 of this form.

 

?          I confirm that to the best of my knowledge, my child / the child in my care does not suffer from any medical condition other than those detailed above.

 

 

Section 7 – Data Protection

 

The Club will use the information provided on this Membership Form (together with other information it obtains about the player) to administer his/her cricketing activity at the Club and in any activities in which he/she participates through the Club and to care for and supervise activities in which he/she is involved.

In some cases this may require the Club to disclose the information to County Boards, Leagues and to the England and Wales Cricket Board. In the event of a medical issue or child protection issue arising, the Club may disclose certain information to doctors or other medical specialists and/or to police, children’s social care, the Courts and/or probation officers and, potentially to legal and other advisers involved in an investigation. 

As the person completing this form, you must ensure that each person whose information you include in this form knows what will happen to their information and how it may be disclosed.

 

By returning this completed Junior Membership Form, I agree to my child taking part in the activities of Liss Cricket Club

 

I confirm that I have legal responsibility for the child named in section 1 above, and that I am entitled to give this consent.

 

I understand that I will be kept informed of activities at Liss Cricket Club – for example details of times and transport etc.

 

I understand that in the event of injury or illness all reasonable steps will be taken to contact me / the alternative contact, and to deal with that injury/illness appropriately.

 

I confirm that to the best of my knowledge all information provided in this form is accurate and I will inform the club of any changes to this information in a timely manner.

 

I confirm that I have received a copy of the club’s Code of Conduct for Members and Guests and agree to abide by it.

 

Name of parent / legal guardian:

 

Signed:

 

Date:

 

 

 (To be completed by the child applying for Junior Membership)

Name:

 

Signed:

 

Date:

 

 

2017 Season

Subs for the season will be charged at £40 per child.  If there is more than 1 child in the family playing cricket, each subsequent child will be charged at £25.

 

I enclose payment for the 2017 as follows:

 

£40 Junior membership             

£25 2nd/3rd child                          

 

Please make cheques payable to Liss Cricket Club

Alternatively, payment can be made online using the following bank details:

Cooperative Bank

Account Number: 65785535

Sort Code: 08-92-99

Please provide player’s name as a reference with payment