Bideford Rugby Club
Junior Section
Membership Application Form
Subscriptions Season - 2017 / 2018
Name of Player
Date of Birth
Address
Post Code
Telephone Number
E-Mail Address (please write clearly)
School
Current School Year
YEAR 1 £25.00
Junior Membership FeesUnder 7s (Year 2) to Under 11s (Year 6) £45
Under 12s (Year 7) to Under 16s (Year11)£55
Subscriptions are due to be paid before the 27th September 2017. Otherwise you are unable to play or attend Practice nights.
Please return this form and money together. Please make cheques payable to Bideford RFC Junior Section
All members MUST have a passport size photo attached when returning this membership form. This is for your RFU ID card.
Bideford Rugby Club
Junior Section
Parental Consent Form
Name of Player
Medical History:
1)Have you suffered from any of the following?
AsthmaYes / No
DiabetesYes / No
EpilepsyYes / No
Heart complaintsYes / No
AllergiesYes / No
Please specify:
Head InjuriesYes / No
If Yes - How long ago
Were you unconsciousYes / No
How long for
Any other major illness or serious previous injuries which may affect participation? Please specify
2)If you have answered yes to any of the above, is the condition under medical control? Yes / No/ n/a
3)Do you need to have any medication during activity? Yes / No
If yes what and how is the form of medication taken
4)Have you had a Tetanus inoculation recently? Yes / No
If not then you are recommended to contact your GP?
5)Your parents / family / next of kin’s names and address
6)Telephone number in case of emergency
I agree to my son / daughter taking part in coaching / fitness test / matches / and any other related activity organized by Bideford Rugby Club Junior Section. In the event of an accident I consent to my son/ daughter to receive treatment. Medical treatment from a responsible medical practitioner and an anesthetic, if this is found to be necessary. At Bideford Rugby Club we believe this is best left to the medical professionals
Parents / Guardian Signature
Please print name Date
Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with a physical or impairment, which has a substantial and long -term adverse effect on his or her ability to carry out their normal day to day activities.
Do you consider yourself to have a disability? Yes / NO
Visual impairment
Hearing impairment
Physical disability
Learning disability
Multiple disabilities
Other (please specify)
Sporting Information
Have you played rugby before? Yes / NO
If yes, where have you played (please indicate below)
Primary school
Secondary School
Local Authority coaching sessions
Club
Other
I agree to my son / daughter / child in my care to taking part in the activities of the Junior Section of Bideford Rugby Club.
I understand that I will be kept informed of these activities (mainly on practice evenings) - for example timing and transport details when playing matches.
I understand that in the event of any injury or illness all reasonably steps will be taken to contact you and Bideford RFC will deal with that injury / illness appropriately.
I understand that Bideford Rugby Club Junior Section may arrange for photographs or videos to be taken of its activities and consent to photographic images of the above named player to be used for promotional and coaches purposes.
If you wish your child’s image NOT to be used please inform you age group coach.
Children must be picked by parents/guardians from within the RUGBY CLUB’SGROUND.
By signing this declaration, I agree to the terms above.
Name of Parent / Guardian
Signature Date
As a Junior Player of Rugby for Bideford Rugby Club I will abide by the Club rules at all times.
Name of Player