Worcestershire disability football club

(Please complete in BLOCK CAPITALS)

Surname

Forenames

Known as

Title

Date of Birth

     

     

     

     

     

Home Address (including Postcode)

     

Home telephone Number

Mobile telephone number

E-Mail Address

     

     

     

FAN Number

Most recent CRB check

     

     

Details of any FA Certificates Held

Date Obtained

     

     

Surname

Forenames

Known as

Title

     

     

     

     

Home telephone Number

Mobile telephone number

E-Mail Address

     

     

     

Reference 1

Reference 2

Name:      

Name:      

Address:      

Address:      

Telephone:      

Telephone:      

Email:      

Email:      

Have you at any time received an

Anti-Tetanus injection?

If yes, please give approximate date

YES/NO      

     

Are you allergic to any medical treatment?

If yes, please give details

YES/NO      

     

Please state if there are any other medical details that you feel are relevant

     

I confirm that I have read and understood the Clubs Rules and Codes of Conduct and I promise to abide by them.

I agree to my photo being used in promotional press releases. I understand that NO name will accompany ANY Photo unless specifically authorised in writing and that every attempt will be made by WDFC to ensure that only authorised photographs are taken.

Name

Signature

Date

     

     

     

Club Secretary, c/o 6 Geraldine Road, Malvern,WR14 3PA or email to secretary@wdfc.org

(UNDER 18 – Form MUST be signed by Parent/Guardian/Carer)