Junior Membership Form

ALEXANDRA PARK CRICKET CLUB

WelcometoAlexandraParkCC.ThisJuniorMembershipFormshouldbecompletedby theparentorlegalguardianofanyplayerundertheageof18andmustalsobesignedbytheplayer.PleasecompletethisformandreturnittoCarolynPritchard.

WewillalsousethisinformationtoensurethatyouarekeptinformedabouteventsandinformationconcerningAlexandraParkCC.

Section1-DetailsofthechildapplyingforJuniorMembership

Name
Age
Address
Name of School / College

Section2-ContactDetailsofParentILegalGuardian

Name
Relationship to Child
Address
Daytime Telephone No
Evening Telephone No
Email

Section3-EmergencyContactDetails(AlternativeContact)

Intheeventofanincidentoremergencysituationwhereaparent,orlegalguardiannamedabovecannotbecontacted,pleaseprovidedetailsofanalternativeadultwhocanbecontactedbytheclub.Pleasemakethispersonawarethathisorherdetailshavebeenprovidedasacontactfortheclub:

Name
Relationship to Child
Address
Daytime Telephone No
Evening Telephone No

Section4-Sportinginformation

Has the child played cricket before? (Please circle) Yes No

If Yes, where have they played Cricket? (Please circle)

Primary School / Secondary School / Special Education Needs School /

Local authority coaching session OR

Club:

County

Other (Please specify)

Section5-informationaboutanyImpairment

Pleaseprovideinformationaboutanyimpairmentyourchildmayhavesothatwecan determine whatreasonableadjustmentsmayberequiredto supportyourchild'sfullparticipationinclubactivities.

DoyouconsideryourchildIthechildinyourcaretohaveanimpairment?

Yes No

Ifyes,whatisthenatureoftheimpairment? (Please circle)

Visualimpairment / Hearingimpairment / Physical impairments / Learningdifficulty / Multipleimpairments

Other(pleasespecify):

IIf youhave circled any of above, pleaseprovideuswithanyadditionalinformationthatwillassistustoensureyourchildisfullysupportedwhilstattheclub.

Section5-MedicalInformation

NameofDoctorISurgery:

DoctorISurgerytelephonenumber:

Medicalconsent:

  • I givemyconsentthatinanemergencysituationtheclubmayactinmyplace,(inlocoparentis),iftheneedarisesfortheadministrationofemergencyfirstaidandIorothermedicaltreatmentwhichintheopinionofaqualifiedmedicalpractitionermaybenecessary. Ialsounderstandthatinsuchanoccurrenceall reasonablestepswillbetakentocontactmeastherelevantparentIlegalguardian, orthealternativeadultI havenamedinsection3ofthisform.
  • I confirmthatto thebestofmyknowledge,mychildIthechildinmycaredoesnotsufferfromanymedicalconditionotherthanthosedetailedabove.

Section7-DataProtection

TheClubwillusetheinformationprovidedonthisMembershipForm(togetherwithotherinformationitobtainsabouttheplayer)toadministerhis/hercricketingactivityattheClubandinanyactivitiesinwhichhe/sheparticipatesthroughthe Clubandtocareforandsuperviseactivitiesinwhichhe/sheisinvolved.

Insomecasesthismayrequire theClubtodisclosetheinformationtoCountyBoards,LeaguesandtotheEnglandandWalesCricketBoard. Intheeventofamedicalissueorchildprotectionissuearising,theClubmaydisclosecertaininformationtodoctorsorothermedicalspecialistsand/ortopolice,children'ssocialcare,theCourtsand/orprobationofficersand,potentiallytolegalandotheradvisers involved inaninvestigation.

Asthepersoncompletingthisform,youmustensurethateachpersonwhoseinformationyouincludeinthisformknowswhatwillhappentotheirinformationandhow it maybedisclosed.

  • ByreturningthiscompletedJuniorMembershipForm,IagreetomychildIthechildinmycaretakingpartintheactivitiesofAlexandraParkCricket club.
  • IconfirmthatIhavelegalresponsibilityforthechildnamedinsection1above,andthatI amentitledtogivethisconsent.
  • IunderstandthatIwillbekeptinformed ofactivitiesatAlexandraParkcricketclub-forexampledetailsoftimesandtransportetc.
  • IunderstandthatintheeventofinjuryorillnessallreasonablestepswillbetakentocontactmeIthe alternativecontact,andtodealwiththatinjury/illness appropriately.
  • IconfirmthattothebestofmyknowledgeallinformationprovidedinthisformisaccurateandIwillinformtheclubofanychangestothisinformationinatimelymanner.
  • I confirmthatIhavereceivedacopyoftheclub'sCodeofConductforMembersandGuestsandagreetoabidebyit.

Nameofparent/legalguardian:

Signed:

Date:

(TobecompletedbythechildapplyingforJuniorMembership)

Name:

Signed:

Date: