Section 1 Personal details for young players and their Parent / Legal Guardian

Name Of Child Date Of Birth dd/mm/yyyy please Name of Parent or Legal Guardian Home Address Postcode Parent Email Home Telephone Work Telephone for parent/guardian Mobile Telephone for parent/guardian

Section 2 Emergency contact details

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 of an alternative adult who can be contacted in an emergency Phone number Relationship to child

Section 3 Disability

The Disability Discrimination Act 1995 defines a disbaled 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 this child to have a disability? Yes If yes, what is their disability? Visual impairment Learning disability Hearing impairment Multiple disability Physical disability Other (please specify below)

Section 4 Sporting Information

Has this child played Cricket before? Yes If yes, where has this been played? Primary school Secondary school Local Authority coaching session Club County Other (please specify below)

Section 5 Medical Information

Please detail below any important medical information that our coaches need to know (e.g. allergies, medical conditions, current medication, special dietary requirement, injuries) Name Of Doctor & Surgery Address Doctor Telephone

Section 6 Consent Statement From Parent / Guardian

Please tick each box where you agree, or leave blank if you do not.

Legal authority to provide consent: I confirm that I have legal responsibility for the child named in Section 1 and am entitled to give this consent. I confirm that to the best of my knowledge, all information provided on this form is accurate and that I will undertake to advise the club of any changes to this information.

Consent to participate: I agree to the child named in Section 1 taking part in the activities of the club.

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 2 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 in section six of this form.

I confirm I have read, or been made aware of, the club’s policies concerning: changing/showering missing children transport children playing in adult matches photography/video anti-bullying and the code of conduct managing children away from the club

Please enter the name of the Parent / Legal Guardian who has completed this form: Please enter a password that you will use to update any details in the future: Please click the SUBMIT button to complete registration.