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City of Sheffield Water Polo (COSWPC) Club

Membership Application Form 2018.

It is a mandatory requirement to have this form signed and returned as part of your acceptance of club membership. Your payment will not be accepted unless accompanied by this completed form.Please complete in block capitals

Membership category (please tick)

RenewalNon-playing member

New MemberPlayer

ASA Registration No (if known)......

Date of Birth......

First names......

Surname......

Correspondence address......

......

......

Postcode......

Telephone (day)......

Telephone (work)......

Email address

(parent’s if under 18)......

If you are a member of any other

swimming or water polo club,

please specify......

Do you require an ASA medical form?YesNo

First Claim Affiliation COSWPC ClubOther (Please State)

(please circle one)

Membership fees - Please tick as appropriate

Players

ASA Category 2 fee (annual)£35.00

Membership fees(monthly)£40.00

Non-players

ASA and Membership fees (annual)£15.00

Method of payment:

CAT 2 fee to be paid by cash or cheque to Sandra Charles memberships secretary all cheques to be made payable to City of Sheffield Water Polo. Any queries email:

Fees are now collected by capitals connect – please see separate form.

Payment Due Dates:

1) MembershipDirect Debits to be paid on the 1st of each month.

2) ASAand non-playing fees before 31st January 2018.

Sheffield Hallam Students:

The fees paid to the Club by Sheffield Hallam University cover pool fees and

training fees for the months from October to May inclusive. Those students

wishing to train in the months of June to September 2018 will need to pay the

pool access and training fee of £40 per month.

I hereby apply to join the City of Sheffield Water Polo (COSWPC) Club for the yearending December 31st 2018.

I agree to be bound by the CONSTITUTION of City of Sheffield Water Polo Club (as amended from time to time) and understand that these shall govern mymembership of the Club.

I agree to pay the required COSWPCand ASA fees by the due dates.

Signed (member)......

Date......

For applications of those under 18 years of age

I am signing on behalf of the applicant, who is under 18 years of age and for whom I am the parent, guardian or carer.

Name....……………………………………...... (Parent, Guardian, Carer) for under 18’s)

Signed...... ………………………………... Date……………………………………………

Medical declaration

ASA guidelines require that all clubs request up-to-date medical information for their players, in case any form of medical assistance is required during training or when attending a match. All players (or a parent/guardian if under 18), must complete and return this form with their membership application.

Member’s Name …………………………………………………………………………………………….

Family GP ………………………………………………………… Tel. ……………………………………………………

Do you have any specific medical conditions requiring treatment and/or medication?

……………………………………………………………………………………………………………………………………………….

Emergency Contacts (for minors only)

Name……………………………………….Tel. ………………………… Relation to child: ……………………………

Name……………………………………….Tel. ………………………… Relation to child: ……………………………

Does your child have an up-to-date tetanus vaccination?YesNo

Does your child have any food, drug or other allergies?YesNo

If yes, please give details: ………………………………………………………………………………………………….

It may be essential at some time for a Club Coach or Team Manager accompanying your son/daughter to have the necessary authority to obtain any urgent treatment which may be required whilst at a competition, trainingoraclub organised trip. Therefore please complete the details on this form and sign below to give your consent.

I,...... Being parent/guardian of the above named child hereby give permission for the Coach or Team Manager to give the immediately necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter's interest, in the doctor's medical opinion, for any delay to be incurred by seeking my personal consent.

Photography and Video (for minors only)

The club may wish to take photographs of individual and groups of swimmers under the age of 18 that may include your child during their membership of the club. All photographs will be taken and published in line with the ASA Photography Policy. Parents have a right to refuse agreement to their child being photographed. As the parent or carer please indicate your permission below. Please note you can withdraw your consent in writing to the club Welfare Officer at any time should you wish to.

Photos to be used on club websiteYesNo

Photos to be included in newspaper articlesYesNo

Photos taken by professional photographer at eventsYesNo

Filming for training purposesYesNo

Signed (parent/guardian)...... ………………………………... Date ……………………………………………

All data collected on this membership form will be kept securely by club personnel and medical/disability information will be provided to teachers/coaches on a need to know basis. If at any time any of the above details change please contact the membership secretary.