Staffordshire Surge - New Player Registration

Please complete this form as fully as possible in order to participate in the Staffordshire Surge American Football (Adult) training sessions.

All information received will be used only for Team purposes, and will not be shared with any third partied, in line with the General Data Protection Regulations (2018).

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First Name(s) *
Surname *
Date of Birth *
Email Address *
Postcode *
Emergency Contact Name *
Emergency Contact Number *
Medical Information

I understand that American Football is a collision sport involving impacts of considerable force. I confirm that my participation in the sport can be potentially dangerous and the likelihood of injury is constantly present.

I hereby voluntarily consent to my participation in all club practice sessions and games.

I understand that participating in any of the above mentioned sessions could involve progressively higher levels of physical activity and that I may be encouraged to work at maximum effort.

I confirm that I am responsible for monitoring my own condition throughout my participation in games, practise and all physical testing. Should any unusual symptoms occur, such as but not limited to chest discomfort, nausea, difficulty in breathing, dizziness, light-headedness, irregular heart beat and joint or muscle injury, I will cease my participation and inform the coach/Committee member of the symptoms.

Also, in consideration of being allowed to participate in club games, practise sessions and all physical testing sessions, I confirm that I have disclosed all medical issues relating to my health and I agree to assume all potential risks from such participation and hereby release and hold harmless Staffordshire Surge and their agents and employees, from any and all health/medical issues that may be aggravated or arise from my participation in any physical activity organised by the club.

Please answer the following 7 questions:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Do you know of any other reason why you should not do physical activity? If you have answered YES to any of the above, please give further details, along with any other comments you may have regarding your medical history that we need to be aware of:
By selecting 'Accept' below and submitting this form, you are confirming that all of the information given above is accurate and up to date, and that should anything change you will contact the club immediately to inform. *
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