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Child's Name *

First Name

Last Name

Gender

Male

Female

Other

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact One

Name

First Name

Last Name

Relationship

Email

Phone

(###)

###

####

Alt. Phone

(###)

###

####

Contact Two

Name

First Name

Last Name

Relationship

Email

Phone

(###)

###

####

Alt. Phone

(###)

###

####

In case of emergency, who should we contact first?

Contact One

Contact Two

Medical Information

Do you consider the child to have a disability?

Yes

No

Prefer Not To Say

If yes, what is the nature of the disability?

Does the child have a medical condition that we need to be aware of? Including medication or allergies

Yes

No

If yes, please provide brief details

Is the child taking medication on a regular basis?

Yes

No

If yes, please provide brief details

Please speak to a member of the Junior Training Team if you would like to discuss any medical issues in further detail

Permissions for Data Storage and Collection

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

Yes

No

GAHC may use the child's 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

The child's image may appear in the press, e.g. local newspaper

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

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

Yes

No

Declaration

By completing this form, I agree to the named child taking part in the activities at this club and acknowledge the need for good conduct and responsible behaviour on their part at all times.

I understand that in the event of an injury or illness all responsible steps will be taken to contact me, and to deal with that injury/illness appropriately. I will also ensure that the club be updated throughout the season with any necessary information that may be of importance to the Junior Training Team.

I give permission for the named child’s coach/team manager to obtain emergency medical treatment should the need arise.

The club will use the information on this membership form (together with other information it obtains about the player) to administer their hockey activity at the club and in any activities in which they participate through the club, and to care for and supervise activities in which they are involved. All data will collected and stored in accordance with our GDPR Data Privacy Notice which is displayed on our website.

By completing this form, I consent to the named child travelling to venues for matches and training by transport provided by Gillingham Anchorians Hockey Club and in accordance with Club Child Welfare Policies, which may include travelling in other players’/parents’ private cars.