Worcestershire disability football club



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WORCESTERSHIRE DISABILITY FOOTBALL CLUB


















COACH / ASSOCIATE REGISTRATION FORM

(Please complete in BLOCK CAPITALS)



Which Position are you applying for (please tick one)?

COACH ASSOCIATE

Surname

Forenames

Known as

Title

Date of Birth

     

     

     

     

     

Home Address (including Postcode)

     

Home telephone Number

Mobile telephone number

E-Mail Address

     

     

     


FA DETAILS

FAN Number

Most recent CRB check

     

     

Details of any FA Certificates Held

Date Obtained

     

     


CONTACT DETAILS IN CASE OF EMERGENCY

Surname

Forenames

Known as

Title

     

     

     

     

Home telephone Number

Mobile telephone number

E-Mail Address

     

     

     




REFERENCES.

Please provide the name, address and contact details for two referees. (Please note that we may contact your referees without prior notification to yourself)

Reference 1

Reference 2

Name:      

Name:      

Address:      

Address:      

Telephone:      

Telephone:      

Email:      

Email:      




MEDICAL QUESTIONNAIRE

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

     


Before signing please read this:  In the event of an injury I give my permission and consent to any immediate treatment deemed necessary by a qualified physiotherapist, First Aider or General Practitioner.

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

     

     

     





PLEASE RETURN FORM TO:   

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)




WDFC COACH / ASSOCIATE APPLICATION FORM

ISSUE 2 (June 2015))





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