Membership (player) registration form 2019/20 Please use a separate form for each player application Players Full name (required) Age group (required) Coach's name (required) Address (required) Postcode (required) Players Date of birth (required) School (required) School year (required) Players nationality (required) Players country of birth (required) Players photo (required) Click to upload image (max file size: 5mb, image format: Jpeg/JPG/PNG) Please note: The photo should be head and shoulders of the player, similar to the style of a passport photo Player's ID (required) Click to upload image (max file size: 5mb, image format: Jpeg/JPG/PNG) We are required by the FA to check all players ID. Please upload a copy of the players birth certificate or passport Contact Telephone number (required) Alternative Telephone number(s) Club officials may occasionally send emails or newsletters as an alternative form of contact. These will be used to inform our players /parents of squad matters, forthcoming events or club news. If you would like to receive info this way, please provide a suitable address below. NOTE: Bleak Hill Rovers will NOT divulge these details to any third party without your prior consent. Email(s) (required) Parent/Guardian Parent/Guardian’s Full Name (required) Parent/Guardian’s Date of Birth (required) Parent/Guardian’s Postcode (required) Parent/Guardian’s Email Address (required) Medical details: Please indicate any medical conditions that we should be aware of e.g. asthma, diabetes, epilepsy, any allergy or intolerance. Please also indicate any family history of heart problems (e.g. Parent or Grandparent / Heart attack, angina, Cardiomyopathy). Nature of medical details Emergency contact details In the event that no-one can be contacted on the above home number, please provide an alternative emergency contact: Contact name (required) Relationship to player (required) Contact telephone number (required) Alternative Contact telephone number Player agreement I agree to be bound by and to observe the Club Rules & the Rules and Regulations of the Football Association and all competition rules in which the Club participates. I confirm that I have read and agree to observe and abide by the Club Codes of Conduct available on the Club web site. Please tick the box (required) YesNo Date (required) Parental consent In the event that my son/daughter is injured whilst playing football/travelling to and from football events and I cannot be contacted on the above number(s), I hereby give consent for my child to receive medical attention. Parent Guardian Declaration: (to be acknowledged by all Parents/Guardians who may accompany the child to a match) I have read and understood the Code of Conduct for Spectators and Parents/Guardians and agree to abide by it at all times. I also agree and understand that sanctions may be imposed on myself and that ultimately these may affect my child should I breach the Codes of Conduct. Furthermore, I also acknowledge and agree that I am a Participant for the purposes of Football Association Rules and Regulations and therefore subject to such Rules and Regulations. Please tick the box (required) YesNo A representative of the Club may occasionally take team photographs for the Club web site or for promotional purposes in the local press. Photographs are taken in accordance with the Child Protection and Best Practice Guidelines issued by the Football Association. If, however, you DO NOT wish your son/daughter to appear on ANY team photos... Please tick the box (required) I don't want my child to appear on photosI'm happy for my child to appear on photos Membership type Please tick a box (required) Just trainingJust playing matchesBoth The club membership fees for the season 2019/2020. a. All fees to be paid directly into the bank – cash or cheques will NOT be accepted. b. Standing Order on 1st of each month or full payment. c. Anyone not paying after one week will not be allowed to play or train. d. Anyone failing to pay by the beginning of the following month will be de-registered and will have to re-apply to play again. e. Anyone who needs support with payment of fees can contact the Welfare Officer who will provide help All members joining before the 31st August must have paid a minimum of £48 before they will be allowed to play in matches. New players joining after 31st August will pay £18 per month. If players wish to pay an annual amount please contact the secretary. The bank details are as follows: NatWestBleak Hill RoversSort Code: 607008Account Number: 58778667 Club Membership fees for the 2019/2020 season are shown in the table below: Team Annual Fee Monthly Fee Pre-league player (Under 6s or younger) £72 £6 Wildcat Girls player £72 £6 League player (u7s to u18s) 1 child £144 £12 League player (u7s to u18s) 2 children £264 £22 League player (u7s to u18s) 3 children or more will be contacted individually Please indicate which form of payment you wish to make by ticking the appropriate box: (required) MonthlyAnnually Please indicate the amount of payment by showing your chosen monthly/annual payment in the payment amount box. If you have more than one child at the club please put the total monthly/annual payment in the payment amount box on the first registration form and a zero in the payment amount box on the second and subsequent registration forms Payment amount (required) I hereby give consent for my child to join the Club and agree to pay as detailed above.Please tick the box (required) YesNo Date (required) Bleak Hill Rovers take our responsibility for looking after information seriously. We follow the data Protection Act at all times when asking for or handling your information including: Personal data will be processed fairly and lawfully and will only be used for purposes for which it was collected. We will not ask for excessive data and it will be kept for no longer than necessary. Data is kept secure against unauthorised access and loss or damage. Sensitive information will be asked for e.g. health information to ensure coaches are aware of any health issues which may affect players. Retention of Information Any information provided to the club will be kept on a password protected computer. Once the player leaves the club all information will be destroyed at the end of the season in which they leave. Agreement By submitting this form you accept all the rules and conditions of the club.