ࡱ>  bjbjVV 4<<R;;8<7 E!("(;";";"###lEnEnEnEnEnEnE$HyKBE#####E;;;";"XE&&&#L;R;";"lE&#lE&&RA"D;" $ϸ#XBXEE0ECK;$K<DKD##&#####EE%###E####K######### : CLUB MEMBERSHIP FORM Club Name:Stockton Hockey ClubMembership Secretary name and contact details:Mark Blackmore  HYPERLINK "mailto:Mark.Blackmore@Barbour.com" Mark.Blackmore@Barbour.com David Yule  HYPERLINK "mailto:Yulehouse@ntlworld.com" Yulehouse@ntlworld.com  All prospective members of Stockton Hockey Club are required to complete this registration form and return it with payment prior to selection for any hockey game. Membership covers the period 1st May to 30th April. All details will be kept in a secure database with access restricted to authorised officers only. SECTION ONE: Member Contact Details Title:Surname:First Name(s):Date of Birth:Daytime phone number:Evening phone number:Home address: POSTCODE:Shirt No:Email: SECTION TWO: Membership type Member TypeDescriptionFeePlease TickSeniorFull Senior Membership 20.00Student/Not EmployedStudents and U18s playing Senior Matches 10.00Junior under 12Junior under 12 unable to play Senior MatchesFree SECTION THREE: Member InformationInformation in this section is optional and will be used for development purposes only Students What school/college or university do you attend?Non-Students What is your occupation?Would you be interested in learning to coach and/or umpire? (Please state)What skills do you have that could help develop Stockton Hockey Club (e.g. web design, accounting, printing) SECTION FOUR: Medical Information and Consent (To be completed by PARENT or LEGAL GUARDIAN if under 18)In case of emergency and as part of the Stockton Hockey Club responsibility to its membership, ALL members are required to complete this medical information form as accurately as possible. Details will be held securely with access restricted to authorised officers only. Next of kin:Relationship:Mobile phone:Doctors name:Surgery:Doctors phone number:As far as you are aware, are you allergic to any medication? (Please state)Are you taking any regular medication? If so, for what reason?Do you have any long term illnesses or injuries? DECLARATION: I consider [myself/my son/daughter]* to be physically fit and capable of full participation and agree to notify Stockton Hockey Club of any changes to the medical information provided. Furthermore, in the event that of injury I give my permission (for myself/my son/daughter)* for the team managers/coaches appointed by Stockton Hockey to obtain emergency medical treatment. Signed:Date: Relationship: SECTION FIVE: Under 18 member consent (to be completed by PARENT or LEGAL GUARDIAN) It is a requirement of Stockton Hockey Club policy that parental/legal guardian consent is provided for participation, transportation and photography. The Stockton Hockey Club Members Code of Conduct and Safeguarding and Protecting Young People Policy are available in the handbook. Please delete as appropriate where indicated by a * then sign and date at the bottom. TRANSPORTATION: I consent to my son/daughter* travelling to venues for matches and training, in transport provided by the club, which may include travelling in other players private cars. PHOTOGRAPHY: In some environments, particularly adult competition it is impossible to control photography by external parties. However, I am aware that there may be times that photographs and/or footage may be taken during matches and training sessions by approved agents and/or officers of Stockton Hockey Club. Such images shall only be used for publicity/training purposes in accordance with the Stockton Hockey Club Safeguarding and Protecting Young People Policy and Photography Policy and I give consent for my son/ daughter to feature in such photos/images. I hereby only grant approved agents the right to use the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes, e.g. local newspapers, local magazines, other promotional articles (including flyers) and the clubs website. Signed:Date: Relationship: SECTION SIX: Ethnicity and disabilityInformation in this section is optional and will be used for development purposes only Ethnicity of club members Please tick the box that best describes your ethnicity TICK TICKWhite BritishAsian or Asian British PakistaniWhite IrishAsian or Asian British BangladeshiWhite OtherAsian or Asian British OtherMixed White and Black CaribbeanBlack or Black British CaribbeanMixed White and Black AfricanBlack or Black British AfricanMixed White and AsianBlack or Black British OtherMixed OtherChineseAsian or Asian British - IndianOther Ethnic Group TICKTICKDeafPhysical disabilityVisually ImpairedLearning disabilityHearing ImpairedMultiple disability Please add any additional relevant information:      Stockton Hockey Club Membership Form 2011-2012 www.stocktonhockeyclub.co.uk Page  PAGE 4 of  NUMPAGES 4 !567fwx     % 0 3 4 H X Z f g x R S [ ^ ` v w x y h'1hFvhdh5\ hdhhdh hjvhdh hF.hdhhIhIH*hI hF.hhP'hrs0J3jhrsUhFvhdh5hrshdhh||5CJaJ 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