GHA JUNIOR RUGBY Midi/ Youth Section 2016/2017 Registration Form
Player First Name *
Your answer
Player Surname *
Your answer
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Year Group for Academic Year 2016/2017 *
Address Line1 *
Your answer
Address Line2
Your answer
Address Line3
Your answer
Post Code *
Your answer
Parent or Guardian's Name *
Your answer
Guardian's relationship to player
Your answer
Home Phone *
Your answer
Mobile Phone *
Your answer
Contact Email Address *
Your answer
Address Line1 of Parent (if different from above)
Your answer
Address Line2 of Parent
Your answer
Address Line3 of Parent
Your answer
Post Code of Parent
Your answer
Alternative Contact Name *
Your answer
Alternative Contact's Phone Number *
Your answer
Alternative Contact's Email Address
Your answer
Relationship of Alternative Contact to Player *
Your answer
Rugby Experience *
Required
School *
Your answer
Player's Doctor *
Your answer
Player's Doctor's Contact Phone Number *
Your answer
Player's Doctor's Address
Your answer
Do suffer from any allergies? *
If yes please give details
Your answer
Do you have a disability? *
If yes please give details
Your answer
Date of Last Tetanus Injections
MM
/
DD
/
YYYY
I consent to being photographed/ videoed during rugby training and games for the Club *
GHA RFC recognises the need to ensure the welfare and safety of players and young people in sport. During the course of the season it is possible you may be photographed for the purposes of rugby coaching and associated activities and promotions including the Club's website, Facebook and Twitter. GHA RFC will take all necessary measures to ensure these images are used solely for the purposes they are intended.
I consent to my receiving emergency medical treatment including anaesthetic as considered necessary by staff present *
Where circumstances permit, all effort will be made to contact the Named Contacts prior to medical treatment commencing.
Player/ Parent Occupations
No obligation to fill this in - the club is always looking for support from its members, utilising skills and contacts where people are willing to help us
Your answer
Thank you for filling out the registration form. By ticking the box below you accept the terms stated by GHA Rugby Club on the Club's website and are willing to pay the appropriate fees. *
Required
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