Personal Details

Full Name               ____________________________________

Home Address       ____________________________________

                                ____________________________________

                                ____________________________________

Postcode                                ____________________________________

Home Tel No          ____________________________________

Mobile Tel No        ____________________________________

Email                       ____________________________________

School/Employer ____________________________________

Date of Birth           ____________________________________

Gender                   ____________________________________

Ethnic Origin

Black                       Chinese                  Other

Disability

Learning                                 Other ____________________

Membership (please tick one of the following 3 options)

Adult Member

£25.00 Joining Fee

£25.00 a month Standing Order

Adult Member

£50.00 Joining Fee

£4.00 per session

£20.00 Joining Fee

£4.00 per session

Please make cheques payable to: Dover Pirates Basketball Club

Discounts available on request to the Club Treasurer.

If you would like to gain a qualification or be a club volunteer, please tick the appropriate box(es)     (* delete as appropriate)

Coach Lvl 1 / Lvl2*                                Table Official Lvl 2 / Lvl 3*

Referee Lvl 1 / Lvl 2               *               Volunteer                / Committee

Emergency Contact

In the event of an emergency please provide contact details of a family member/ friend. Compulsory for those aged 16yrs or under.

Full Name               _____________________________________

Relationship to      _____________________________________

Home Tel No          _____________________________________

Mobile No               _____________________________________

Work No                 _____________________________________

Important Information

Please provide full information regarding:

·          Medical Condition, including current medication

·          Cultural Issue

·          Ability/Disability Level

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Use a separate sheet if necessary

From time to time club members may be filmed [photographic and / or video images]. If you do NOT wish to be included in any team photos or publicity materials such as; poster campaigns, flyers or websites, please tick here: [   ]

This information is required for club administration and in the interest of your safety should an emergency occur. All details will be handled in a secure and confidential manner in accordance with the Data Protection Act legislation. 

Signature

^{I have read and agree to adhere to the following club documents:}

• ^{Equity Policy}
• ^{Codes of Conduct & Disciplinary Procedure}
• ^{Child Protection & Vulnerable Adult Policy}

^{I agree to immediately notify the club committee of any changes in the above listed medical conditions. In the event of an injury whilst training or competing, I hereby give consent to receive medical attention.}

^{Signature ___________________________________________}

^{Print Name__________________________________________}

^{Must be a Parent/Guardian if under 16years}