ࡱ> GIFg bjbjVV *r<r< "ZZ((($LLLL<$Lr*:1$1$1$)))))))$+^.*(y'}1$y'y'* ,*!)!)!)y'R()!)y')!)!)"!)`w'!))B*0r*!).'.!).(!)1$$!)s%l%1$1$1$**E(1$1$1$r*y'y'y'y'.1$1$1$1$1$1$1$1$1$Z z:  REGISTRATION FORM - 2011/2012 SEASON BURGESS HILL RUGBY FOOTBALL CLUB JUNIOR & MINI SECTION Manager: Mark Stenning, 78 Leylands Rd, B/Hill. RH15 8AJ. Mobile: 07973111992 Data Protection Act 1984 - To facilitate the provision of information and newsletters to our members all details given below will be recorded on a database. This is not used for any other purpose nor will it be so used without your prior consent. Should you have any objection to such a record being maintained you are entitled to request exclusion by writing to the Club Secretary.  (Please complete all sections. One form per player)  Players Name:  Address:  Post Code  D.O.B: Age on 01/09/2011  School the player attends  Home Telephone: Parents Mobile: Players Mobile: ________ Parents / Guardians Email: (Please write this clearly and be aware that we use e-mail as our main form of communication)  Emergency Contact Name (1): Contact Number  Emergency Contact Name (2) Contact Number (You must be contactable on one of these numbers whilst your child is in our care)  Medical Conditions including allergies Medication: (We will administer inhalers with your written permission. Please label with child name.)  Previous Rugby Experience: Please tick the box if you do NOT want your child to have taken or be used in the following: Photo:Video:Internet: Ethic Origin (Tick where appropriate) White: British Mixed: White & Black Caribbean Asian and Asian British: Indian Black or Black British:Caribbean White: Irish Mixed: White & Black African Asian and Asian British: Pakistan Black or Black British: Africa White: Other Mixed: White and Asian Asian and Asian British: Bangladesh Black or Black British: Other Chinese Mixed: Other Asian and Asian British: Other Other Ethnic Group BHRFC Membership 2010/2011: 60 for the season. (incl. 50 for family membership + 10 for 1 playing child). Additional children in the same family - 10 only (New Players are offered a 2 week free trial) Full payment is required at time of registration. Please contact either the Registration Officer (as detailed on the information board in the clubhouse) or the players coach to discuss any other payment arrangements Payments should be made by either cash or cheque made payable to BHRFC. . 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