All members of Buckingham Hockey Club are required to complete this registration form and return it to the Treasurer with payment prior to selection for the league season. This information will be used to keep you informed about Club events and to contact you in the event of an accident or incident. Some of the information is required to comply with the England Hockey Equity Policy, which has been adopted by the Club. All details will be kept in a secure database with access restricted to authorised club officers only.

SECTION 1: MEMBER CONTACT INFORMATION

TITLE / Mr/Mrs/Miss/Ms (Please circle)
FULL NAME
ADDRESS 1 / DATE OF BIRTH
ADDRESS 2 / HOME PHONE
TOWN / MOBILE PHONE
POST CODE / EMAIL

SECTION 2: MEMBERSHIP TYPE

The table below sets out the membership types available. Club policy states that all returning members and new members joining before 1st November must sell the designated number of 300 club tickets at £10 per ticket, a crucial fund raising activity for the club. These tickets are charged at the time of membership and can be sold on to reclaim the value of the tickets.

MEMBER TYPE / FEE / 300 CLUB / TOTAL TO PAY / Please Tick
RETURNING MEMBERS AND NEW MEMBERS JOINING BY 31st OCTOBER / First Team Squad Senior Membership paid for by Sponsor (complete section 6) / £260 / 8 tickets@ £10 = £80 / £80
Other Senior Membership paid for by Sponsor (complete section 6) / £200 / 8 tickets@ £10 = £80 / £80
Senior Membership / £150 / 8 tickets@ £10 = £80 / £230
Casual senior membership (max 10 matches) / £75 / 1 ticket@ £10 = £10 / £85
Full-Time Students and U18s Membership / £100 / 4 tickets@ £10 = £40 / £140
Junior Membership (U16 and younger) / £100 / 1 ticket@ £10 = £10 / £110
Student, U18 or Junior whose parent is a senior member / £80 / N/A / £80
NEW MEMBERS JOINING AFTER 1ST NOVEMBER / Senior Membership without 300 Club membership / £150 / N/A / £150
Full-Time Students, U18s & Junior Members without 300 Club membership / £100 / N/A / £100
NEW MEMBERS JOINING AFTER 1ST JANUARY (HALF SEASON) / Half-Season Senior Membership / £90 / N/A / £90
Half-Season Full Time Students, U18s and Juniors / £60 / N/A / £60
TASTER MEMBERSHIP / Taster Membership (max 3 training sessions) / £20 / N/A / £20
SOCIAL / Non-Playing / Vice Presidents / £20 / N/A / £20

SECTION 3: MEMBER INFORMATION

Information in this section is optional and will be used for club development purposes only. Parents are also encouraged to take a role in the club so please let us know if your parents would like to become involved.

STUDENTS – What school/college or university do you attend?
Would you be interested in learning to coach and or umpire? (Please state)
Would you be interested in being a team manager or club officer? (Please state)
What skills do you have that could help develop the club? (e.g. web design, accounting, printing, planning, sponsorship, etc)
Playing History (County, Regional, National Honours and Age Group)

Continued …


SECTION 4: MEDICAL INFORMATION & CONSENT

(To be completed by PARENT or GUARDIAN if under 18)

In case of emergency and as part of the clubs responsibility to its membership, ALL club members are required to complete this medical information form as accurately as possible. Details will be held securely with access restricted to authorised club officers only.

NEXT OF KIN / EMERGENCY CONTACT / RELATIONSHIP / MOBILE
DOCTORS NAME / SURGERY / PHONE
Do you have any allergies?
Do you have any medical conditions the Club should be aware about? Do they require medication? If so, what?
Do you have any long term illnesses or injuries?
Declaration: I consider myself (my child) to be physically fit and capable of full participation and agree to notify the club of any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission (for my child) for the team managers/coaches appointed by Buckingham LHC to obtain emergency medical treatment on my behalf.
SIGNED / DATE / RELATIONSHIP

SECTION 5: UNDER 18 MEMBER CONSENT (TO BE COMPLETED BY PARENT/GUARDIAN)

It is a requirement of club policy that parental consent is provided for participation, transportation and photography. The Buckingham LHC members Code of Conduct and Safeguarding and Protecting Young People in Hockey Policy are available on the Club website.

TRANSPORTATION: I consent to my child travelling to venues for matches and training by transport provided by the club which may include travelling in other player’s private cars.

PHOTOGRAPHY: In some environments, particularly adult competition it is impossible to control photography by external parties, however, I am aware that there maybe times that photographs and/or footage maybe taken during matches and training sessions by approved agents and/or officers of Buckingham LHC. Such images shall only be used for publicity/training purposes in accordance with the Buckingham LHC Safeguarding and Protecting Young People in Hockey Policy and Photography Policy and give consent for my child to feature in such photos/ images. I hereby only grant approved agents the right to use the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes ie local newspapers, local magazines, other promotional articles (inc. flyers) and the club’s website.

COMMUNICATION: The club will endeavour to ensure parents receive a copy of all communications sent to players under the age of 18. To ensure we are able to do so, please give a parent’s email address here.

PARENT’S EMAIL ADDRESS / OR TICK IF SAME AS SECTION 1
SIGNED / DATE / RELATIONSHIP

SECTION 6: SPONSORSHIP (ONLY SPONSORED PLAYERS (from section 2) SHOULD COMPLETE THIS SECTION).

Information in this section enables us to promote and contact individual player sponsors. For club sponsorship opportunities please see our

sponsorship booklet or contact the BLHC Sponsorship & Fundraising Representative:

SPONSORED PLAYER / DESCRIPTION
SPONSOR NAME
BUSINESS NAME
SPONSOR EMAIL
BRIEF DESCRIPTION
SPONSOR LOGO / Logo must be sent to for inclusion on the website and in newsletters

Continued …


SECTION 7: ETHNICITY & DISABILITY

Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have existed within sport particularly in relation to gender, race and disability. Sport England and England Hockey are committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of people in sports clubs, national governing bodies of sport and Sport England can identify any issues relating to under representation of different groups and can develop strategies to ensure that all people have the opportunity in the future to develop and progress in sport.

England Hockey requests this data from clubs as part of the annual affiliation process and completing this data accurately enables the club to give an accurate picture to England Hockey on our membership. This information is not held against your record in the club database. Completing this section is optional. PLEASE TICK THE RELEVANT BOXES.

ETHNICITY OF CLUB MEMBERS / LEARNING OR PHYSICAL DISABILITY
TICK BOX / TICK BOX / TICK BOX
White British / Asian or Asian British - Pakistani / Deaf
White Irish / Asian or Asian British - Bangladeshi / Visually impaired
White Other / Asian or Asian British – Other / Hearing impaired
Mixed –White and Black Caribbean / Black or Black British – Caribbean / Physical disability
Mixed – White and Black African / Black or Black British – African / Learning disability
Mixed – White and Asian / Black or Black British – Other / Multiple disability
Mixed – Other / Chinese
Asian or Asian British – Indian / Other Ethnic Group

SECTION 8: PAYMENT

Payment Summary

AMOUNT
MEMBERSHIP COST / £
300 CLUB COST / £
OTHER COST / £
TOTAL PAYMENT / £

Please tick the relevant option:

Send a cheque made payable to ‘Buckingham Hockey Club’ to: Treasurer BLHC, 9 Station Road, Winslow, Buckingham MK18 3DZ.
Bank Transfer of money and email application form to .
Account name: Buckingham Hockey Club
Account number: 47101334
Sort Code: 60-04-09
Reference: SUBS (your surname)
Hand membership form and payment to coaching team at training prior to subs deadline.

www.buckinghamhc.co.uk