Fives and Heronians Cricket Club

Below is a link to a document which is exactly the same as the from below. To complete this form, click the link and fill it in. 

Colts membership application form-9.pdf 

FIVES AND HERONIANS CRICKET CLUB

Membership Form

We are very pleased to welcome you to Fives and Heronians Cricket Club. In case of an emergency is it important that we have the correct details for you so we would be grateful if you could fill out this Membership Form and return it to the head of junior cricket.

If you are under the age of 18 please also ask your parents / carer or legal guardian to sign the Membership Form before it is returned. We will also use this information to ensure that you are kept informed about events and information from Fives and Heronians Cricket Club.

Section 1 – Personal Details (young people under the age of 18)

Name:
Date of Birth:
Name of School / College:

Section 2 – Personal Details (Parent / Legal Guardian)

Name:
Address:
Postcode:
Home telephone number:
Work Telephone number:
Mobile:
Email:

Section 3 – Disability

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’.

Do you consider yourself to have a disability?		Yes	No
If yes, what is the nature of your disability?
Visual impairment
Hearing impairment
Physical disability
Learning disability
Multiple disability
Other (please specify):

Section 4 - Sporting Information

Have you played Cricket before?			Yes	No
If yes, where have you played Cricket: (please indicate below)
Primary school
Secondary school
Special Education Needs School
Local authority coaching session(s)
Club
County
Other (please specify)

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 etc.)

Medical consent:

• I give my consent that in an emergency situation, the Club may act 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 that all reasonable steps will be taken to contact me or the alternative adult which I have named in section 6 of this form.
• I confirm that to the best of my knowledge, my child does not suffer from any medical condition other than those detailed by me above.

Section 6 – 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:
Relations which this person to the young person:	E.g. Aunt, neighbour etc…
Address:
Postcode:
Home telephone number:
Work Telephone number:
Mobile:

Section 7 - Automatic Non- Voting Membership Status

Junior membership of the club also provides that the parent(s) / carer(s) / guardian(s) of the child are given non-voting membership of the club as part of that junior membership.  This entitles the parent(s) / carer(s) / guardian (s) no additional privileges that would otherwise be gained by paying the appropriate adult membership fee(s). Any use of facilities (for example social / training / playing) may incur such charges as applicable to relevant adult membership. 

Section 8 – 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 Membership Form, I agree to the child in my care taking part in the activities of Fives and Heronians Cricket Club.

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

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

Signed: (Young Person)
Print: (Young Person)
Date:

Signed: (Parent / Legal Guardian)
Print: (Parent / Legal Guardian)
Date: