Chalfont St Peter Cricket Club – Junior Member Registration Form

Chalfont St Peter Cricket Club – Junior Member Registration Form
This form must be completed by the Parent or Legal Guardian of any player under the age of 18, signed by them and
by the player and returned to the relevant age-group manager, it will be collated and stored centrally.
Data protection. The Club will use the information provided on this form (together with other information it obtains about the
player “Information”) to administer his/ her cricketing activity at the Club and in any activities participated in 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 (ECB). In the event of a medical 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.
Section 1 Personal details for young player and their Parent(s)/Legal Guardian(s):
Name of Child (under 18)
Child’s date of birth (dd/mm/yy)
Primary contact (Parent or Legal Guardian)
Home address
Home phone number
Primary mobile number:
Primary Work number:
Primary Email address
… used for all communications from the club
Secondary contact (Parent or Legal Guardian)
Secondary mobile telephone number:
Secondary email address:
Section 2 Emergency alternative contact detail:
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 their details have
been provided as a contact for the Club.
Name of an alternative adult contactable in an emergency
Phone number for alternative named adult
Relationship this person has to the child (e.g. Aunt,
neighbour, family friend etc)
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 this child to have a disability?
Yes
If yes, what is the nature of their disability? (circle those that apply)
Visual impairment Hearing impairment Physical disability Learning disability
Other (please specify):
No
Section 4 Sporting information:
Has the Child played Cricket before?
Yes
No
If yes, where has this been played? (circle those that apply)
Primary school
Secondary school
Local authority session(s)
Club
County or Devt
Other (please specify):
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 requirements, injuries):
Doctor’s / Surgery Name:
Doctor’s Telephone number:
Surgery address:
Consent Statement from Parent / Legal Guardian - tick each box for agreement and leave blank for disagreement
I confirm that for the for the child named above I (a) have legal responsibility, (b) am entitled to give this
consent to the best of my knowledge, (c) confirm all information provided on this form is accurate, (d) permit
images of the named child being used on the club website and in publicity material associated with the club
(eg local paper), and (e) undertake to advise the club of any changes to this information
I agree to the child named above a) taking part in the activities of the club, and b) being photographed /
filmed for the purposes of coaching only.
Medical consent: I give my consent that in an emergency situation the Club may act in loco parentis. I
understand that, 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, all reasonable steps will
be taken to contact me or the alternative adult named in section 2 above.
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 5 of this form
Club policies: I confirm I have been made aware of and read the club’s policies concerning: changing /
showering; missing children; children playing in adult matches; transport; Anti-bullying and the code of
conduct; photography / video; managing children away from the club
I would be interested in helping in some way as the club operates largely through voluntary assistance –
someone will contact you to discuss how you can help
My child and I understand and agree to comply with the club policies listed above.
Signed (Parent / Legal Guardian):
Printed name of Parent / Legal Guardian who has
completed this form:
Date of signing:
Signed (Child – for compliance with club policies):