ࡱ> _a^ QbjbjVV .`<<Q rr$L$rx e<5o"0LA(,>,F$ji"Lr {: LEADERSHIP AWARD NOVEMBER 2010. ROTHERHAM HOCKEY CLUB. Candidate Registration/Consent Form This form MUST be co-signed by your parent or person with legal responsibility if you are under 18 yrs of age. It represents authorisation for you to participate as a candidate on the Leadership Award/Foundation Umpire Award. Full Name of participantDOBFull postal addressCountyEmailTelephone numbersName of Emergency Contact Emergency Contact Numbers MEDICAL INFORMATION & CONSENT (To be completed by PARENT or person with legal responsibility if you are under 18 yrs. of age) In case of emergency and as a responsibility on behalf of England Hockey, ALL young candidates are required to complete this medical information as accurately as possible. Details will be held securely with access restricted to course organisers and England Hockey. Do you/your child experience any conditions requiring medical treatment and/or medication? If yes please provide details No Do you/your child have any allergies? If yes please provide details No Do you/your child have any specific dietary requirements? If yes please provide details  No Please provide any further information you think is relevant: I confirm to the best of my knowledge that I/my child* does not knowingly suffer from any medical condition other than those detailed above and that I will inform England Hockey if this changes. I consent to my child receiving medical treatment which in the opinion of a medical practitioner may be necessary. SIGNED DATERELATIONSHIP EthnicityDisabilityWhite BritishDeafWhite IrishVisually impairedWhite OtherHearing impairedMixed- White and Black CaribbeanPhysical disabilityMixed White and Black AfricanLearning disabilityMixed White and AsianMultiple disabilityMixed OtherAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British -OtherBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - OtherChineseOther Ethnic Group I ________________________ (name of young person) do/do* not give England Hockey permission to hold my personal details. Signed _________________________________ Date __________________________ * Please delete as appropriate  I _______________________ am the parent of the above and have full knowledge of their action in regard to this form and the Leadership Course/Foundation Umpire Award Assessment. 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