AFC Portchester Membership
MEMBERSHIP AND CONSENT FORM – To be completed for anyone under 18 years old.
Childs First Name *
Childs Surname *
Childs Date of Birth *
MM
/
DD
/
YYYY
Place of Birth *
Team *
Second Team (Cross-Signing)
Home Address *
Post Code *
Medical Details *
Please indicate if your child has any medical conditions we should be aware of (e.g. asthma). Include details of any known allergies and all current medication:
Emergency Parent/Carer Details 1 *
Required
First Name *
Last Name *
Parent/carer’s date of birth *
MM
/
DD
/
YYYY
Parent/carer’s FAN number
Emergency Contact No *
Email Address *
Confirm Email Address *
Emergency Parent/Carer Details 2 *
In the event that the above named person cannot be reached, please give an extra emergency contact name and number:
Required
First Name *
Last Name *
Emergency Contact No *
Parent/Guardian Signed *
I have seen AFC Portchester’s Code of Conduct. Having read the Code I agree to abide by it. I agree that my child will behave in accordance with the club’s disciplinary procedures and code of conduct. I give permission for my son/daughter to have their picture displayed on the AFC Portchester website for advertisement and promotional purposes. In the event that my child is injured whilst playing football/travelling to and from football events and I cannot be contacted on the above number, I hereby give my consent for my child to receive medical attention. I agree that the club can use my contact details to keep me informed about events and activities which may be of interest.
Required
Player Signed *
I have understood and will abide by the club’s rules and procedures.
Required
Date Signed *
MM
/
DD
/
YYYY
COMPLETE THE FOLLOWING IF SIBLING IS PLAYING FOR AFC PORTCHESTER
Sibling Name
Sibling Date of Birth
MM
/
DD
/
YYYY
Sibling Team
Macron Training Kit Size *
Data Protection *
I confirm that I have read, understood, and agree to the AFC Portchester Youth Privacy Policy (Click here to view - http://www.afcportchesteryouth.co.uk/news/117-privacy-policy)
Required
All monthly subscriptions will be collected by Direct Debit.
If paying by direct debit, please note that AFC Portchester Youth FC has appointed the BACS Approved Direct Debit Bureau, Eazy Collect Services Limited (www.eazycollect.co.uk), to collect your payments. AFC Portchester will be shown on your bank statement for these direct debit payments.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy