Belmont United YFC Club Annual Membership, Information and Consent Form

This form is to be completed and signed by Parent/Legal Carer and Child when joining the Club. Parent/Legal Carer is responsible for informing the club of any changes as they occur. It is important that you fill in this form as fully as possible, as failure to share relevant information could mean that the safety and welfare of your child is compromised and the Club cannot be held responsible.

Season:______/______

Player’s Full Name: Boy /Girl (circle)
D.O.B:
Age Group: U….
Player’s Home Address:
Tel. Number (Home and Mobile):
Emergency Only Tel. Number:
e-mail (s): / Photo

Parent’s / Legal Carer’s Details

Full Name:
Home Address (If different from Player’s):
Tel / Mob Number (s):
e-mail:
*If the child is not living with parent(s) please clarify the legal status of the child and his/her current carer(s):

Health Needs

Does your child have any known health needs? (e.g.: Diabetes, Asthma, Epilepsy, Allergies, etc):
Yes / No (circle) *If Yes, please complete section below
Condition:
Current Medication, Dose and Frequency:
How can Club help to keep your child well? (e.g. administer planned medication, snack, call ambulance, etc):
Does your child have any access needs? Please explain:

Communication

Does your child have any communication needs, e.g. Non-English Speaker, Learning Difficulties, Dyslexia, Hearing Impairment, Sign Language, etc? If Yes, please explain:

Religion and Culture

What does Club need to know to ensure your child’s preferences / needs are met? e.g. Dietary Guidelines, Dress Codes, etc:

Images

At times the Club may wish to take photos or videos of the team, or individuals in it. We adhere to The FA’s Photography/Video Guidelines to ensure these are safe, respectful and appropriate and are used solely for the purposes intended, which is promotion and celebration of the activities of the Club and for training purposes.
Please indicate if this is acceptable for you? Yes / No
*For any additional information please contact the designated Club Welfare Officer (CWO) Valdet Aliu. Contact details are visibly displayed at the Club’s home ground, and on the Club’s website. The FA’s Photography Guidelines leaflet is available to access via our website.

Additional Activities

There may be occasions when your child is involved in planned and structured non-football activities such as a trip to the cinema, bowling or participating in a fund raising event. The Club will have collected appropriate information in preparation for the activity (e.g. about the journey, the children’s various needs and helper skills), identified any potential risks or dangers, minimised the risks and dangers by careful planning and precautions and made sure we know who is responsible for putting precautions into place (e.g. who will carry the First Aid kit). This process is called a Risk Assessment and every Team Manager will be responsible for appropriately delegating or carrying out one if individual teams undertake such activities as above.

Consent of Parent / Legal Carer

I give consent for my son/daughter to participate in Belmont United Youth Football Club’s activities / events and agree to the conditions outlined in p.1 and p.2 above. I accept that it is my responsibility to inform the Club directly of any changes to the details / circumstances recorded on this form.
Signed (Legal carer):
Please print name:Date:

Player’s Consent

*If you are over 11 years of age, sign Section A *If you are under 11 years of age, sign Section B

Section A
I agree to participate in Belmont United Youth Football Club’s activities / events as detailed above and agree to adhere to guidelines and codes of conduct that may be issued in the interest of my own safety.
Signed (Player):
Please print name:Date:
Section B
I will take part in the Belmont United Youth Football Club’s activities and will stick to the Club rules. I will tell the coach or another person if I do not feel well or if I have any worries.
Signed (Player):
Please print name:Date:

Disclaimer

Belmont United Youth Football Club would advice all playing members of the Club that they do so at their own risk. The Club does not accept liability for injury, loss or damage to either persons or valuables whilst taking part in activity for the club, either on the field of play or any area under the control of the Club. The Club recommends that you take out individual insurance.

All Club and Team Officials, Players, Parents and other Family Members and Spectators should be aware and at all times adhere to the Club’s Codes of Conduct and appropriate Respect Guidelines. For any further information please contact Kim Weight (07522940128) or visit our website:

The information on this document is subject to the Data Protection Act 1998 and for the Club’s use only.