2016/17 Player Membership Form
Age Group: ………………………………………………
Team color: ……………………………………………...
Manager: …………………………………………………
Child's full name: ...... Date of Birth: ...... /...... /......
Address: ......
………………………………………………………………………………………………………..
Parent /Guardian (Name & Relationship)…………………………………………………………………..
Contact number:………………………………………………………………………………………………
E-Mail (Capitals) ………………………….…………………………………………………………………
Parent /Guardian (Name & Relationship)…………………………………………………………………..
Contact number:………………………………………………………………………………………………
E-Mail (Capitals) ………………………….…………………………………………………………………
Child’s School……………………………………………. School Year Group (Sept 2016)………..
I ...... would like to register as a member of St Andrew's Football Club Under ………squad for the above season and agree to abide by the clubs rules and code of conduct.
Player’s signature ...... Date ...... /...... /......
I enclose: £65 to cover Club membership and training for the whole season
(£60 for siblings)
New Members – not yet registered with Portsmouth FA
I enclose: copy of Birth certificate or copy of passport
This section and Medical Form must to be completed by the Parent/Guardian of the young person named above.
I confirm I have watched theFA RESPECT for Parents Video (
I agree to abide by the clubs rules and code of conduct and understand that all kit provided by Hayling St Andrews Football Club remains the property of the Club and must be returned (clean) to the Club at the end of the season, or when a player leaves the Club. It is the responsibility of the parent or guardian to ensure the kit is kept in good repair and condition.
Parent/Guardians signature ...... Date ...... /...... /......
MEDICAL INFORMATION / CONSENT Please answer the following questions as fully as possible. In the event of your child requiring emergency treatment, it will help the medical authorities in deciding which the most appropriate treatment to give is.
(Please complete in BLOCK CAPITALS)
Child's full name: …………………………………………………………………
Parent/Guardians Full name: ......
Relationship to Young Person: ......
HAS YOUR CHILD BEEN ACTIVELY IMMUNISED AGAINST TETANUS?
YES / NODate of last Tetanus injection: ...... /...... /...... (Estimate if unsure)
DOES YOUR CHILD SUFFER FROM ANY ILLNESS?
Asthma: YES / NO Detail: ………………………………………………………………………..
Heart Condition: YES / NO Detail: ………………………………………………………………………..
Severe headaches: YES / NO Detail: ………………………………………………………………………..
Diabetes: YES / NO Detail: ………………………………………………………………………..
Allergies: YES / NO Detail: ………………………………………………………………………..
Other: YES / NO Detail: ………………………………………………………………………..
ANY REGULAR MEDICATION BEING USED YES / NO
Details: ………………………………………………………………………………………………………
………………………………………………………………………………………………………………...
ADDITIONAL INFO WE MAY NEED TO KNOW
Details: …………………………………………………………………………………………………......
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………...
Family Doctors Information
Surgery Name: ………………………………………………………………………………..
Address: ......
…………………………………………………………………………………………
Tel No's......
If it becomes necessary for my child to receive medical treatment and I cannot be contacted by telephone or any other means to authorize this, I hereby give my general consent to any necessary medical treatment and authorize the Team Manager(s) (or in their absence one of the Assistant Managers), to sign any document required by the Medical Authorities.
I will inform the Team Manager if any of the information given on this form changes during the course of the season.
Parent/Guardian signature...... Date ...... /...... /......