Junior Signup 2022 Season – Golborne Cricket Club

Section 1 - Players Information

Personal Details of the child applying for Junior Membership

Players Name *

First

Last

Date of Birth *

School Year *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

School/College *

Section 2 - Parents Information

Parents Name *

First

Last

Relationship to Child *

Parents Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Section 3 - Alternative Emergency Contact Details

In the event of an incident or emergency situation where a parent, or legal guardian named above cannot be contacted, please provide details of an alternative adult who can be contacted by the club. Please make this person aware that his or her details have been provided as a contact for the club:

Name *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Section 4 - Sporting Information

Has the child played cricket before *

Where have they played cricket before

Primary School
Secondary School
Special Educational Needs School
Local authority coaching session(s)
Club
County

Section 5 Information about any Impairment

Please provide information about any impairment your child may have so that we can determine what reasonable adjustments may be required to support your child’s full participation in club activities.

Do you consider your child / the child in your care to have an impairment?

If yes, what is the nature of the impairment?

Visual impairment
Hearing impairment
Physical impairment
Learning difficulty
Multiple impairments
Other

If you have ticked yes in any box above please provide us with any additional information that will assist us to ensure your child is fully supported whilst at the club.

Section 6 – Medical Information

Name of Doctor/Surgery

Doctor/Surgery Telephone Number

Medical Details

Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, current medication, injuries etc.)

Section 7 - Permisssions

I confirm I have legal responsibility for……………………………………………….(name of child) and am entitled to give this consent. *

I confirm to the best of my knowledge, all information provided on this form is accurate, and I will undertake to advise the club of any changes to this information. *

I give my consent that in an emergency situation, the club may act in my place (loco parentis), if the need arises for the administration of emergency first aid and/or other medical treatment which, in the opinion of a qualified medical practitioner, may be necessary. I also understand that in such an occurrence all reasonable steps will be taken to contact me or the alternative adult which I have named in section two of this form *

I confirm to the best of my knowledge, my child / the child in my care does not suffer from any medical condition other that those detailed by me in section 5 of this form *

I agree to the child named above taking part in the activities of the club. (This consent only relates to JUNIOR cricket. Please see the Open Age cricket policy for more information on juniors playing in open age group cricket)

I confirm I have read, or been made aware of, the club’s policies concerning: *

Changing / showering
Transport Children
Photography/Video
Managing Children Away from the Club
Missing Children
Playing in Adult Matches
Anti Bullying and the code of conduct
I understand and agree to the responsibilities which I and my child have in connection with these policies
I consent to the club photographing or videoing my involvement in cricket under the terms and conditions in the club photography / video policy (NOTE: LEAVE THIS BOX UNTICKED IF YOU DO NOT AGREE)
I also confirm have been given all the details that are currently available for the home and away fixtures in which my child may participate

Signature *

By entering your name here you confirm you have filled in this form accurately and agree to adhere to the rules of Golborne Cricket Club