Name of Player (required)

Name of Player 2 (if registering more than one member of your family)

Name of Player 3

(if registering more than three members of your family please get in touch or download a printable form above)

Home Address (required)

Post code (required)

Date of Birth (required)

Date of Birth Player 2

Date of Birth Player 3

Email address (required)

Mobile Telephone Number (required)

Home Telephone Number

School Attended Player 1 (required)

School Year Player 1 (required)

School Attended Player 2

School Year Player 2

School Attended Player 3

School Year Player 3

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Section 2 – Contact Details of Parent / Legal Guardian

Name (required)

Relationship to child e.g. parent / legal guardian (required):

Home Address (If different from player):

Daytime telephone number (required):

Evening telephone number (required):

E-mail (If different from player):

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Section 3 – Emergency Contact Details

This section MUST be completed by the parent / carer or guardian:

Please insert the information below to indicate the persons who should be contacted in the event of an incident / accident: Please make sure the people being used for this purpose are aware that the club holds this information;

Emergency Contact 1:
Name (required)

Relationship to child e.g. parent / legal guardian (required):

Home telephone number (required):

Work telephone number (if relevant):

Mobile telephone number:

E-mail (If different from player):

Home Address (If different from player):

Emergency Contact 2:
Name

Relationship to child e.g. parent / legal guardian:

Home telephone number:

Work telephone number (if relevant):

Mobile telephone number:

E-mail:

Home Address:

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Section 4 – SPORTING EXPERIENCE INFORMATION:

Have you played cricket before?
YesNo

If yes, where has this been played? (e.g. Club, Primary School, Secondary School, Special Educational Needs School, Chance To Shine Coaching by Club, Local Authority Coaching Sessions)

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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?
YesNo

If yes, what is the nature of the impairment?
Vision impairmentHearing impairmentMobility impairmentDexterity impairmentLearning difficultyMultiple impairmentsOther (please specify):

Other:

If your child has any impairment, please provide us with any additional information that will assist us to ensure your child is fully supported whilst at the club.

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Section 6 – 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.

Medical consent:

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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

Play-Cricket Results Data

I consent to the club using my child’s name on Mistley Cricket Play Cricket sites for results input

NB [If you do not agree please leave un-ticked]

Play Cricket Data consent:

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Section 8- Photography

I consent to the club using photography or videoing my child’s involvement in cricket under the terms & conditions in the Club photography / video policy please tick

NB [If you do not agree please leave un-ticked]

Club Photography consent:

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ECB SAFE HANDS

For all matters regarding Child Welfare please look at the ECB Website or consult club welfare officer Simon Garnham on 07887 841818.

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

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

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 in the event of injury or illness all reasonable steps will be taken to contact me, 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/carer/guardian (required):

Signature of parent/carer/guardian (required):
Club Photography consent:
[acceptance* E-Signature-Guardian]

Signature of Junior Member 1 (required):
Club Photography consent:
[acceptance* E-Signature-Member-1]

Signature of Junior Member 2:
Club Photography consent:

Signature of Junior Member 3:
Club Photography consent:

Date:

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Sponsorship

The club may also wish to share your e mail address with Sponsors and Business partners; should you not wish your details to be disclosed please tick the box

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Please Read: Volunteers Needed

As with any organisation we cannot run without the help of volunteers. If you have a skill which you feel you could offer to the club please let us know via this form, just tick the appropriate box below and leave contact details, it could be that there is someone in your family who would like to help with preparing wickets, cutting the outfields or doing teas etc, we would like to know;
Fundraising;Teas/Catering;Work On The Ground:Event organisation:Coaching:Scoring:General Administration:Cleaning/Maintenance:

Volunteer Name:

Volunteer Telephone:

Would you like to sign up to the Mistley Cricket Club Newsletter and stay up to date with club events, news and offers?
YesNo