Mid Sussex Chargers Basketball Club

NATIONAL & LOCAL JUNIOR CLUB MEMBERSHIP FORM

2016 / 2017 SEASON

U16 / Senior Local League / Years 10 & 11
T Fee :£16 monthly / U14 / Boys National
League / Years 7-9
T Fee:£20 monthly
U13 / Local League / Years 7 & 8
T Fee : £16 monthly / U14 / Local League / Years 8&9
T Fee:£16 monthly
MEMBERSHIP INFORMATION - Please tick in the appropriate box for the team you wish to enter. An Annual Registration fee of £30 and a separate Training Fee is payable on joining as a junior member.
Bank A/c Details : Sort code 40-11-65 Account No :50001651 A/C Name: Mid Sussex Chargers Basketball Club
There will be separate Match Fees depending on type of team competition entered.

Player Details

Name of Player / Date of Birth
Address
Postcode
School / School Year
Main Email
(main contact)
Home Telephone / Players Mobile

Parent/Carer Details

Name(s) / Mobile
Mobile
Email / Home Phone

Medical Information

Does your child have any medical conditions/allergies that we should be aware of?
Please Provide details of any medications that your child carries or must be administered?
Does your child have any current/past injuries or disabilities that we should be aware?
YES/NO
If yes please give details :

Photography / Film

Please tick here ☐

I give consent for photographs of the participant to be used for publicity purposes for promotion of the club and further camps or courses run by MS Chargers.

Declaration

  • I agree to my child taking part in the activities of Mid Sussex Chargers.
  • I confirm that to the best of my knowledge that my child does not suffer from any medical condition and/or allergy, other than those listed above.
  • I understand that Mid Sussex Chargers accept no loss,damage or injury caused by or during attendance on any of the organized activities, except

wheresuch loss damage or injury can be shown to result directly from the negligence of an MS Chargers representative.

  • I acknowledge that my child is expected to attend and be on time for every training session as outlined in the national training schedule.
  • I acknowledge that my child is expected to maintain good behaviour and be respectful of staffand other participants.
  • I acknowledge that my child is expected to show an active interest in improving skills and put inthe appropriate effort needed.
  • I have read and agree to abide by Mid Sussex Chargers Code of Conduct at all times.
  • I understand the Code of Conduct applies to all players, parents and spectators.
  • I understand that any fees for training or events must be paid promptly.
  • I agree to my son/daughter receiving medication as instructed and any emergency dental,medical or surgical treatments as considered necessary by the medical authorities present.

NOTE: Parent/Carer(s) will be contacted in the case of emergency – please ensure your Emergency Contact info is provided on page 1.

Signature ______DATED______

(Parent/Guardian)

Printed Name ______

Please return form to team coach or the Club Secretary Caroline Maraj confirming payment and 2 passport size photos and proof of age.

Under the Data Protection Act: The information on this form will be held on a computer system. The data will only be available to coaches and officers of Mid Sussex Chargers for the sole purpose of administering Mid Sussex Chargers events and affairs.Under the Child Protection Act: Mid Sussex Chargers has appointed an officer Alison Bodhain accordance with theguidelines produced by England Basketball. Please contact your child’s coach for further details.