Membership Registration Form

2003-2004 Playing Season Age Group – Under______

Personal Details
Full Name (player)
Home Address
Home Telephone	Date of Birth

Education Details
Head Teacher	School
Current School Year	School Tel.

Medical Details Please indicate if your son/daughter has/had any medical conditions we should be aware of e.g. Asthma
Name of Family Doctor	Telephone
Address

Parent/Guardian & Emergency Details
(1) First Name	Surname
Home Phone	Mobile
(2) First Name	Surname
Home Phone	Mobile

Alternative Contact In the event that the above named persons cannot be reached, please give alternative emergency contacts
(1) Name	Telephone
(2) Name	Telephone

Parental Consent In the event that my son/daughter is injured whilst playing football/travelling to and from football events and the named persons (1) or (2) cannot be reached on the above numbers, I hereby give my consent for my child to receive medical attention.
Signed	Print Name
Date

I agree to be abound by and to observe the Club Rules and the Rules and Regulations of The Football

Association Limited and County Football Association, and all competitions in which the club participates.

I enclose £______as membership fee to be repayable if this application is not successful.

I consent to disclosure by County Football Association.

Membership fee: £12 U8 and above. Cheques payable to: Horrabridge Rangers Sports Association.

Parent/Guardian Signature

Club Secretary