MEMBER REGISTRATION FORM

All prospective members of Basildon Hockey Club are required to complete this registration form prior to the start of each season. The season runs from the 2nd August each year; in the interest of the welfare of our members, any players who have not completed a membership form will not be allowed to play league matches or attend training until it has been completed.

* = Required

What type of membership are you applying for? *

SECTION 1: MEMBER CONTACT INFORMATION

Title *

First Name(s) *

Last Name *

Address Line 1 *

Address Line 2

Town

Postcode *

Gender

Date of Birth *

Home Phone

Mobile Phone *

Email Address *

SECTION 2: MEMBERSHIP TYPE

Please choose your membership type from the list below: *

MEMBERSHIP DETAILS

Senior - Ladies

Annual Fee: £180

Match Fee: £10 per game

SECTION 3: MEMBER INFORMATION

Information in this section is optional and will be used for Club development purposes only

STUDENTS - What College/University do you attend?

NON-STUDENTS - What is your occupation?

Do you have a Coaching Qualification?

Do you have an Umpire Qualification?

Do you have a First-Aid Qualification?

Do you have a Safeguarding Qualification?

If you don't have a coaching qualification, would you be interested in learning to Coach?

If you don't have an umpiring qualification, would you be interested in learning to Umpire?

Would you be interested in training as a Goalkeeper?

What other skills do you have that could help develop the Club?

e.g. Web Design, Accounting, Printing, Planning, Sponsorship etc

SECTION 4: MEDICAL INFORMATION & CONSENT

In case of emergency and as part of the Club's responsibility to its membership, all Club members are required to complete this medical information form as accurately as possible. Details will be held securely with access restricted to authorised Club officers only.

Next of Kin

Full Name*

Relationship *

Mobile Phone *

Doctor Information

Doctor's Name *

Surgery *

Phone *

As far as you are aware, do you have any allergies? *

If yes, please state

Are you taking any regular medication? *

If so, for what reason?

Do you have any long-term illnesses or injuries? *

If yes, please state

DECLARATION

I consider myself to be physically fit and capable of full participation and agree to notify the Club of any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission for Basildon Hockey Club to seek emergency medical treatment on my behalf.*

CODE OF CONDUCT

The Basildon Hockey Club Code of Conduct can be found here. All members must agree to follow these rules of conduct.*

SECTION 5: MEMBER CONSENT

PHOTOGRAPHY

There may be times that photographs and/or footage is taken during matches and/or training sessions by appointed members and/or officers of Basildon Hockey Club. Such images shall only be used for publicity/training purposes. The following consent allows Basildon Hockey Club to share images which include yourself on social media platforms, the Club website, flyers and leaflets and in printed media (for example team photos in the local newspaper) in order to promote the hockey club.

I hereby give consent for myself to feature in such photos/images and only grant appointed members the right to use the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes i.e. local newspapers, local magazines, other promotional articles (inc. flyers) and the Club's website. *

SECTION 1: YOUTH MEMBER INFORMATION

Title *

First Name(s) *

Last Name *

Gender

Date of Birth *

SECTION 2: PARENT/GUARDIAN CONTACT INFORMATION

Title *

First Name(s) *

Last Name *

Home Phone

Mobile Phone *

Email Address *

Address Line 1 *

Address Line 2

Town

Postcode *

SECTION 3: MEMBERSHIP TYPE

Please choose your membership type from the list below: *

MEMBERSHIP DETAILS

Youth

Annual Fee: £60

Match Fee: £3 per game

SECTION 4: MEMBER INFORMATION

Information in this section is optional and will be used for Club development purposes only

What School does your son or daughter attend?

Would your son/daughter be interested in training as a Goalkeeper?

Does your son/daughter have a First-Aid Qualification?

Does your son/daughter have an Umpire Qualification?

If your son/daughter does not have an umpire qualification, would they be interested in learning to Umpire?

What skills do you have that could help develop the Club?

e.g. Web Design, Accounting, Printing, Planning, Sponsorship etc

SECTION 5: MEDICAL INFORMATION & CONSENT

To be completed by Parent or Guardian

In case of emergency and as part of the Club's responsibility to its membership, ALL Club members are required to complete this medical information form as accurately as possible. Details will be held securely with access restricted to authorised Club officers only.

Next of Kin

Full Name*

Relationship *

Mobile Phone *

Doctor Information

Doctor's Name *

Surgery *

Phone *

As far as you are aware, is your son/daughter allergic to any drugs? *

If yes, please state

Is your son/daughter taking any regular medication? *

If so, for what reason?

Does your son/daughter have any long-term illnesses or injuries? *

If yes, please state

DECLARATION

I consider my son/daughter to be physically fit and capable of full participation and agree to notify the Club of any changes to the medical information provided. Furthermore, in the event that my son/daughter is injured I give my permission for Basildon Hockey Club to seek emergency medical treatment on my behalf. I will also ensure my son/daughter is wearing a gumshield and shinpads during all training sessions and matches.*

CODE OF CONDUCT

The Bsildon Hockey Club Code of Conduct can be found here. All members must agree to follow these rules of conduct.*

SECTION 6: MEMBER CONSENT

To be completed by Parent of Guardian if under 18.

It is a requirement of Club policy that parental consent is provided for participation and transportation and photography.

TRANSPORTATION

I consent to my son/daughter travelling to venues for matches and training by transport provided by the Club which may include travelling in other players/parents private cars. *

PHOTOGRAPHY

There may be times that photographs and/or footage is taken during matches and/or training sessions by appointed members of Basildon Hockey Club. Such images shall only be used for publicity/training purposes in accordance with the England Hockey's Guidance for Taking and Using Photographic and Recorded Images of Young People (SafeD Policy). The following consent allows Basildon Hockey Club to share images which include yourself / your son or daughter on social media platforms, the Club website, flyers and leaflets and in printed media (for example team photos in the local newspaper) in order to promote the hockey club.

I hereby give consent for my son/daughter to feature in such photos/images and only grant appointed members the right to use the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes i.e. local newspapers, local magazines, other promotional articles (inc. flyers) and the Club's website. *