Membership Form 2018
PLEASE COMPLETE IN BLOCK CAPITALS
First Name(s)Surname
Activity
Venue
Contact Details
Address
Postcode / Contact Number
Date of Birth / / / / / Age / Male / Female
Name of school / college
School Year
Emergency Contact Name
Emergency Contact Number
What is your ethnicity? Please circle below
Asian: British – Bangladeshi - Indian - Pakistani - Sri Lankan - Other ______
Black: British – Caribbean – African – Somalian – Congolese – Nigerian - Other______White: British - Irish – European – Cypriot – Turkish – Kosovan – Kurdish - Other______Other: Chinese – Moroccan – Iraqi – Iranian – Latin American – Arab– Other______
Mixed Race: WhiteBlack Caribbean - White & Black African – White & Asian – Other ______
Childs First LanguageChilds Second Language
Doctor Information and Medical Information– Please tick and/or complete the boxes
Name of GP
GP Contact Number
Do you / does your child have a disability or statement of ‘Special Educational Needs’? / Yes / No
Please give details
Do you / does your child have any conditions requiring medical treatment, including any medication you will need access to on a regular basis while attending? / Yes / No
Please give details
Do you / does your child have any allergies? / Yes / No
Please give details
Do you / does your child take any medication for asthma? / Yes / No
Please give details
Any other relevant information? (medication, diet, behaviour etc) / Yes / No
Please give details
Parent Information – Please read the print and sign name
Medical Consent
It may be essential from time to time for the Coach or Team Manager accompanying your son/daughter to have the necessary authority to obtain any urgent treatment which may be required whilst at The Access to Sports Project activities or training therefore, please complete the consent form below.
My child is in good health and I consider him/her capable taking part in The Access to Sports Project activities. I have completed the medical details consent that in the event of any illness / accident any necessary treatment can be administered to my child, which may include the use of anaesthetics. I also understand while Coaches will take every precaution to ensure that accidents do not occur, they cannot necessarily be held responsible for any loss, damage or injury suffered to my child.
Photo and Video Consent
I acknowledge that certain activities may involve my child/children being photographed or filmed for promotional use and therefore agree to contact The Access to Sports Project office should I disagree to this activity.
Research, Monitoring and Evaluation
I acknowledge that The Access to Sports Project may undertake research questionnaire, monitoring and evaluation exercises involving child / children to measure the effectives of our work. Involvement in these activities will be purely voluntary and participants can pull out of the research at any time. I agree to contact The Access to Sports Project office should I disagree with this activity.
Data Protection
As part of our work we are required to keep basic information on participants (name, address, date of birth, gender, ethnicity, qualifications, education or employment status) in instances this information will be shared with our partners (e.g. youth and leisure departments in Islington, Haringey and Hackney and other funders). We will handle the information you have provided in line with the provisions of the Data Protection Act. Any personal information will be held in confidence with only the necessary people able to see or use it. For more information contact The Access to Sports Office.
Occasionally we mail information on sports course etc which we believe will be of interest to our customers.
Please tick the box if you would like to receive such information [ ].
I will inform the Access to Sports Project of any changes in the child/young person’s personal details,including changes to parent/guardian due to a court order, significant injuries or head injuries, medical or other circumstances between now and for the continuation of time that my child/young person attends the project.
Date / / / /Parent / Guardian First Name
Parent / Guardian Surname
Signature