Laurel Park FC 2017/18 Registration and Consent Form

Confidentiality: Details on this form will be held securely and will only be shared with coaches or others who need this information in order to meet the specific needs of your child. Email addresses will be used by Laurel Park FC representatives, or by partners in relation to Laurel Park FC activities (e.g. League registration with Gotfootball, Registration to The FA through Wholegame system & Reading Women FC as part of the FAWSL Sister Club program).

Player Details
Name of Player:
Address:
Date of Birth:
September School Year:
Gender: / Male / Female
Home Telephone Number:
Names of Parents / Carers:
Daytime Number of Parent / Carer 1: / Mobile Number of Parent / Carer 1:
Daytime Number of Parent / Carer 2: / Mobile Number of Parent / Carer 2:
Email Address Parent / Carer 1:
Email Address Parent / Carer 2:
Emergency Contact Information:
Name of an alternative adult emergency contact: / Relationship to Player:
Daytime number for Alternative adult: / Mobile number for Alternative Adult:
Please confirm if there are any activities your child cannot participate in: / Please give details:
Medical Details
Any specific medical conditions requiring medical treatment: / Yes (please give details): / No:
Details of medication required:
Any specific disabilities: / Yes (please give details): / No:
Any allergies: / Yes (please give details): / No:
Details of any dietary
requirements: / Yes (please give details): / No:
Date of last tetanus injection:
Name of Family Doctor: / Phone number of Family Doctor:
Address of Family Doctor:
Consent Information and Declaration - please tick the boxes below
I/WE HEREBY AGREE THAT IN THE EVENT OF AN ACCIDENT AND THAT WE ARE NOT PRESENT THE TEAM MANAGER HAS OUR AUTHORITY TO CONTACT EITHER A DOCTOR OR CALL FOR AN AMBULANCE ON OUR BEHALF. / □
I/WE GIVE CONSENT THAT IF AN EMERGENCY MEDICAL SITUATION ARISES, THE ORGANISATION/CLUB MAY ACT AS LOCO PARENTIS. IF THE NEED ARISES FOR ADMINISTRATION OF FIRST AID AND/OR OTHER MEDICAL TREATMENT WHICH IN THE OPINION OF A QUALIFIED MEDICAL PRACTITIONER MAY BE NECESSARY INCLUDING ANAESTHETIC OR BLOOD TRANSFUSION. I ALSO UNDERSTAND THAT IN SUCH CIRCUMSTANCES THAT ALL REASONABLE STEPS ARE MADE. / □
I/WE ACCEPT SOLE RESPONSIBILITY FOR ARRANGING TRAVEL TO AND FROM HOME AND AWAY MATCHES FOR THE ABOVE PLAYER. THE CLUB SHALL HAVE NO LIABILITY FOR SUCH TRAVEL ARRANGEMENTS WHETHER OR NOT THE PLAYER TRAVELS WITH A TEAM MANAGER/COACH OR OTHER PLAYER REPRESENTATIVE. / □
WE HAVE READ AND SIGNED THE LAUREL PARK FOOTBALL CLUB CODE OF CONDUCT FOR PLAYERS, PARENTS AND COACHES / □
I/WE WILL NOTIFY LAUREL PARK FOOTBALL CLUB AS SOON AS POSSIBILE OF ANY CHANGE IN THE MEDICAL OR OTHER CIRCUMSTANCES OF THE PLAYER / □
I/WE AGREE TO OBTAIN CONSENT FROM THE TEAM MANAGER TO TAKE PHOTOS/VIDEO AT TRAINING/MATCHES & WILL NOT DO SO IF CONSENT IS NOT GIVEN. I/WE ALSO AGREE NOT TO USE ANY IMAGES TAKEN ON OPEN SOCIAL MEDIA PLATFORMS / □
LAUREL PARK WOULD LIKE TO USE PHOTOS OF TEAMS AND PLAYERS ON OUR SOCIAL MEDIA PLATFORMS. PLAYERS' NAMES WILL NOT BE ASSOCIATED WITH THEIR PHOTOS AND IMAGES WILL ONLY BE TAKEN IN A FOOTBALLING CONTEXT. LAUREL PARK DOES HAVE A SOCIAL MEDIA POLICY TO CONTROL USAGE OF OUR PLATFORMS. PLEASE CONFIRM YOUR ACCEPTANCE OF THIS. / YES / □ / NO / □
Signature of Parent / Carer:
Name of Parent / Carer:
Date:

This form, or an electronic copy of it, will be taken to each event by the Team Manager.