We are very pleased to welcome you to the HAYFIELD CRICKET CLUB.

To ensure we have the correct contact details for you, please fill out this form and give it back to NAME OF JUNIOR COACH COORDINATOR.

If you are under 16, please also ask your parent or carer to sign the form before it is returned. We will also use this information to ensure that you are kept informed about club events.

Name

Address

Postcode

Home telephone number

Mobile*

Email*

Date of Birth

* Neither the mobile number nor the email should be that of the child – this could make children vulnerable and is considered poor practice. For a child/young person these details should be those of the parent/carer.

Whilst it is not compulsory that the following section is completed the footnote at the end of this template explains why it is important.

In order to help the club monitor its membership please will you tick one of the following boxes to identify your ethnic group/origin.

A

White c

British c

Irish c

Any other white background (please specify) ___________________________________________

B

Mixed c

White & Black Caribbean c

White & Asian c

White & Black African c

Any other mixed background (please specify) __________________________________________

C

Asian or Asian British c

Indian c

Pakistani c

Bangladeshi c

Any other Asian background (please specify) ___________________________________________

D

Black or Black British c

Caribbean c

African c

Any other Black background (please specify ___________________________________________

E

Chinese or other ethnic group c

Chinese c

Any other (please specify) ___________________________________________________________

The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial long-term adverse effect on his or her ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability? Yes c No c

If yes, what is the nature of your disability?

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

Visual impairment c

Hearing impairment c

Physical disability c

Learning disability c

Multiple disability c

Other (please specify):

Have you played CRICKET before? Yes c No c

If yes, where have you played the sport: (please indicate below)

Primary school c

Secondary school c

Local authority coaching session(s) c

Club c

County c

Other (please specify):

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

To be completed by the parent/carer

Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident.

Contact name e.g. parent/carer

Emergency contact number:

By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the club.

I understand that I will be kept informed of these activities – for example timing and transport details.

I understand in the event of injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.

Name of parent/carer:

Signature of parent/carer: Date: