Parent/Guardian

Personal and Medical Records and Consent Form

Team

Name Date of birth

Address

Postcode

School attended

1. Does your son/daughter require to have medication with them when taking part in sport?

Yes No If yes, what kind?

Dosage Time taken

With whom/where will this medication be kept?

2. Has your son/daughter ever had any of the following?

Asthma Yes No Diabetes Yes No

Epilepsy Yes No Heart complaints Yes No

3. Does your son/daughter have any allergies? Yes No

If yes, please specify

4. Does your son/daughter have any other illness/injuries that may affect participation?

Yes No

If yes, please specify

5. Is your son/daughter considered disabled? Yes No

6. Ethnicity: White/British European Black or Black British Mixed

Asian or Asian British Chinese or other

Signed: Print name: Date:

Relationship to team member:

(If under 18 years of age, a parent or guardian must sign above. Please state relationship to team member).

THIS FORM WILL BE RETAINED IN CONFIDENTIAL FILES AND IS FOR USE IN EMERGENCIES ONLY

Please complete and sign the consent form overleaf

Full Name of parent/guardian Mr / Mrs/ Miss

Home phone number ( )

Emergency phone number ( )

(if different from above)

Mobile Phone number

Email Address

As a member of Whaley Bridge Cricket Club your son/daughter will be involved in training and playing in competitions, both at home and away venues. All sessions will run under the guidance of appointed coaches. Your son/daughter will be subject to the ECB/Club Code of Good Conduct.

Please complete the following and sign and return to the Team manager. Players will not be able to take part until the form is returned. If you have any queries, please do not hesitate to ask the Team Manager.

Consent:

l I agree to my son/daughter taking part in the activities of Whaley Bridge Cricket Club

l I consent to my son/daughter travelling by minibus or motor vehicle driven by a Whaley Bridge Cricket Club official or any other authorised parent, to an event in which the team is participating.

l I authorise the leader of the party, or any other Whaley Bridge Cricket Club official accompanying the party who may be present, to consent to such medical treatment (including inoculations, blood transfusions or surgery) which in the opinion of a qualified medical practitioner may be necessary during any period of time when my son/daughter is with the Whaley Bridge Cricket Club and away from direct parental control and direction.

l I authorise that my child can have photographs/video taken of them related to

Whaley Bridge Cricket Club and used for promotional and training purposes.

· I authorise that my child can use changing rooms whilst in use by senior players.

Signed Date

Relationship to team member