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Newham CC Membership Form
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* Indicates required question
First Name
*
Your answer
Surname
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Email address
*
Your answer
Address
*
Full address including post code
Your answer
Mobile number
*
Your answer
Ethnicity
*
Choose
White or White British
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Sri Lankan
Asian or Asian British: Afghan
Black or Black British
Mixed or Multiple
Other
Do you consider yourself to have a disability?
*
Yes
No
Details of disability
Your answer
Emergency contact name
*
A responsible adult who can be contacted in case of an emergency involving you.
Your answer
Emergency contact number
*
A responsible adult who can be contacted in case of an emergency involving you.
Your answer
Relationship to player
*
How is the emergency contact related to the player?
Your answer
Name of doctor / GP
*
Your answer
Name of surgery
*
Your answer
Surgery contact number
*
Your answer
Medical conditions
Please state any other medical information, such as allergies/conditions that you believe our staff should be aware of.
Your answer
Photo / Video consent
*
I give consent for photos and videos of me / my child being taken for club purposes.
Yes
No
Medical, data protection & membership terms consent
*
Please confirm that you give medical consent, and consent to the membership and data protection terms detailed below the form?
Yes, I consent.
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