Data Protection. The club will use the information provided on this form (together with other information it obtains about the player) (together “Information”) to administer his / her cricketing activity at the Club and in any activities in which he / she participates through the Club, and to care for and supervise activities in which he/she is involved. In some cases this may require the club to disclose the information to County Boards, Leagues and to the England & Wales Cricket Board. In the event of a medical issue or child protection issue arising, the Club may disclose certain information to doctors or other medical specialists and /or to police, children’s social care, the courts and /or probation officers and, potentially to legal and other advisers involved in an investigation.

As the person completing this form, you must ensure that each person whose information you include in this form knows what will happen to their information and how it may be disclosed.

Section 1:- Personal details for young player and their Parent / Legal Guardian
Name of Child

Child’s Date of BirthName of Parent or Legal Guardian
Home address

PostcodeEmail address
Home telephone number

Work telephone number for parent / guardianMobile telephone number for parent / guardian
Section 2:- Emergency Contact Details
In the event of an incident or emergency situation, where a parent or legal guardian named above cannot be contacted, please provide details of an alternative adult who can be contacted by the club. Please make this person aware that his or her details have been provided as a contact for the club.
Name of an alternative adult who can be contacted in an emergency

Phone number for alternative named adultRelationship which this person has to the child (e.g. Aunt, neighbour, family friend etc)

Section 3 :- Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’.
Do you consider this child to have a disability ?  Yes  No
If yes, what is the nature of their disability ?
 Visual impairment  Learning disability  Other (please specify)
 Hearing impairment  Multiple disability
 Physical disability

Section 4 :- Sporting Information
Has the child played Cricket before ?  Yes  No
If yes, where has this been played ?
 Primary School  Local Authority coaching sessions
 Club  Other (please specify)
 County

What age group do you wish to register the child for ? (Age as at 31st August)

 Under 9 Kwik Cricket  Under 11  Under 13

(Year 3 & 4) (Year 5 & 6) (Year 7 & 8)
Section 5:- Medical Information
Please detail below any important medical information that our Coaches need to know
(e.g. allergies, medical conditions, current medication, special dietary requirements, injuries)

Name of Doctor / Surgery Name

Doctor’s Telephone number

Consent statement from Parent / Legal Guardian
Please tick each box where you agree (or delete if you do not agree)
Legal authority to provide consent:
 I confirm that I have legal responsibility for (Name of child)

and am entitled to give this consent __________________________

 I confirm that to the best of my knowledge, all information provided on this form is accurate, and that I will undertake to advise the club of any changes to this information.

Consent to participate:
 I agree to the child named above taking part in the activities of the club.
Medical consent:
I give my consent that in an emergency situation, the Club may act in loco parentis, if the need arises for the administration of emergency first aid and / or other medical treatment which in the opinion of a qualified medical practitioner may be necessary. I also understand that in such an occurrence that all reasonable steps will be taken to contact me or the alternative adult which I have named in section 2 of this form.
I confirm that to the best of my knowledge, my child does not suffer from any medical condition other than those detailed by me in section 6 of this form.
I confirm I have read, or been made aware of, the club’s policies concerning

Changing / showering  Missing children
Transport  Children playing in adult matches
Photography / video  Anti bullying and the code of conduct
Managing children away from the club

I understand and agree to the responsibilities, which my child and I have in connection with these policies.

I confirm that I have been provided with a copy of the Club’s ‘Code of Conduct’ for both Members and Guests of this Club, and also a ‘Code of Conduct’ for Junior Members. I understand and agree that both my child and I will adhere to the ‘Code of Conduct’ at all times, and that failure to do so

may result in my child being excluded from membership of the Club.

I consent to the Club photographing or videoing my child’s involvement in cricket under the terms and conditions in the Club photography / video policy. [NOTE: THIS BOX SHOULD BE LEFT UNTICKED IF YOU DO NOT AGREE]

I also understand that when they are known, I will be given comprehensive details of the home and away fixtures in which my child may participate.

Signed (Parent / Legal Guardian): Date of signing:

Printed name of Parent / Legal Guardian who has completed this form: