We are very pleased to welcome you to NAME OF CLUB.
To ensure that we have the correct contact details for you, please
insert the information requested below and return this form to
NAME OF JUNIOR COORDINATOR. If you are under 16 please also ask
your parents or guardian to sign this form before it is returned.
We will also use this information to ensure that you are kept
informed about club events.
Personal details
Name:
Address:
Postcode:
Home telephone number:
Mobile: email:
Date of birth: Gender: Male ¨ Female ¨
Sports equity monitoring
Whilst it is not compulsory that this section is completed the
following paragraph explains why it is important.
Sport can and does play a major role in promoting the inclusion
of all groups in society. However, inequalities have traditionally
existed within sport, particularly in relation to gender, race
and disability. Sport England is committed to promoting and developing
sports equity, which is about fairness in sport, equality of access,
recognising inequalities and taking steps to address them. By
monitoring the profile of young people in sports clubs, national
governing bodies of sport and Sport England can identify any issues
relating to under-representation of different groups and can together
develop strategies to ensure that all young people have the opportunity
in the future to develop and progress in sport.
Ethnicity
In order to help the club monitor its membership can you please
tick one of the following boxes to identify your ethnic group/origin:
Choose one section from A to E and then tick the appropriate box.
White
Mixed
Asian or Asian British
Black or Black British
Chinese or other ethnic group
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 yourself to have a disability? 0 Yes 0 No
If yes, what is the nature of your disability?
Visual impairment
Hearing impairment
Physical disability
Learning disability
Multiple disability
Other(please specify):
Sporting information
Have you played NAME OF SPORT before? Yes No
If yes, where have you played the sport: (please indicate below)
Primary school
Secondary school
Local authority coaching session (s)
Club
County
Other (please specify):
Medical information
Please detail below any important medical information that our
coaches/junior coordinator should be aware of (e.g. epilepsy,
asthma, diabetes, etc.)
Emergency contact details
To be completed by parent/carer
Please insert the information below to indicate the person(s)
who should be contacted in case of an incident/accident:
Contact name (e.g. parent/carer):
Emergency contact number:
By returning this completed form, I agree to my son/daughter/child
in my care taking part in the activities of the club.
I understand that I will be kept informed of these activities
- for example timing and transport details.
I understand that in the event of any injury or illness all reasonable
steps will be taken to contact me, and to deal with that injury/illness
appropriately.
Name of parent/carer:
Signature of parent/carer:
Date: