SIGN UP

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact - Phone *

(###)

###

####

Do you consider yourself to have a disability? *

Yes

No

Prefer Not To Say

If yes, what is the nature of the disability?

Do you have a medical condition that we need to be aware of? Including medication or allergies *

Yes

No

If yes, please provide brief details

Are you taking medication on a regular basis? *

Yes

No

If yes, please provide brief details

In order to help the club monitor its membership, please identify your ethnic group or leave blank if you prefer not to say

Permissions for Data Storage and Collection

GAHC may photograph/video me at training or matches for the purpose of coaching analysis *

Yes

No

GAHC may use my image in publicity material, including the website *

N.B. No personal or identifying information will be posted with any video or photo without permission

Yes

No

GAHC may contact me with information they believe I may find useful, related to my hockey membership, e.g. training courses, supporting opportunities, etc. *

Yes

No

My image may appear in the press, e.g. local newspaper *

Yes

No

GAHC and its officers may contact me through email, phone or social media purely for the purposes of administering club business *

Yes

No

The Club will use the information on this membership form to administer your hockey activity at the club and in any activities in which you participate through the club. All data is collected and stored in accordance with our GDPR Data Privacy Notice.

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 the team managers/coaches appointed by Gillingham Anchorians HC to obtain emergency medical treatment on my behalf.

I, the above named, wish to apply to be a member of Gillingham Anchorians Sports Facility Limited* and hereby agree to be bound by the Articles of Association, to any terms for membership, its rules and to guarantee the debts to a maximum amount of £1.