Cumnor Minors Football Club
An FA Charter Standard Club affiliated to the Berks & Bucks FA
Consent and Registration 2014/15 (U6s)
Please complete this form if your son/daughter wishes to take part in Cumnor Minors FC
training in the 2014/15 season. You must also pay the relevant fee for him/her.
Player’s details
Player’s full name…………………………………
School attended……………………………………
Date of birth ………………………………………
Team: Under 6s
Parental Consent
(please complete a separate form for each child)
I agree for my above named son/daughter to take part in football and other related activities
organised by Cumnor Minors FC during the 2014/15 season.
Medical information

Does your son/daughter have any physical or mental conditions that require treatment or medication,
or that you think we need to know about?
YES / NO
If YES, please give brief details (including the type of pain relief /other medication your son/daughter
may be given):
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
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Is your son/daughter allergic to any medication?
YES / NO
If YES, please give brief details:
……………………………………………………………………………….…………………………………………
………………………………………………………………………………………………………………….………
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When did your son/daughter last have a tetanus injection?
………………………………………………………………………………………………………………………….
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To the best of your knowledge, has your son/daughter been in contact with any contagious or infectious
diseases or conditions in the last four weeks?
YES / NO
If YES, please give brief details:
………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………….
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Please give details of your son/daughter’s doctor.
Name……………………………………………………………………………………………………………………
Address…………………………………………………………………………………………………………………
Phone……………………………………………………………………………………………………………….…..
Equalities (please also complete the monitoring information on page 4)
Does your son/daughter have any other extra needs (for example, emotional, diet, dress, language,
religious or cultural requirements)?
If YES, please give brief details:
YES / NO
…………………………………………………………………………………………………………………………
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Your details
Parent or guardian’s full name
Second parent or guardian’s full name
…………………………………………………………
………………………………………………………....
Home phone …………………………………………
Home phone …………………………………………
Work phone ………………………………………….
Work phone ………………………………………….
Mobile…………………………………………………
Mobile…………………………………………………
Email………………………………………………….
Email………………………………………………….
Home address ……………………………………… Home address (if different) …………………………
………………………………………………………...
………………………………………………………...
…………………………………………………………
…………………………………………………………
Post code ……………………………………………
Post code ……………………………………………
Emergency contact
Please give details of another contact in case of emergency
Name …………………………………………………………………………………………………………………….
Contact phone number(s) ……………………………………………………………………………………………..
Address ………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
Fees (please pay the TOTAL below)
U6s subscription for 2014/15
£40
Voluntary donation under the Gift Aid scheme
TOTAL
£15*
£55 Less £10 if paid before the due date
LESS £10 i.e. £45 if paid before 14TH September 2014 to your manager
Please note that the subscription fees and gift aid are not refundable in the event of your child electing to
give up, transferring to another club or being unable to continue playing for any other reason.
* Please complete the Gift Aid declaration on page 3 so we can claim tax relief on your donation.
 Deduct £10 per player from the subscription element if you have two or more players in the Club or you
are the manager.
 Deduct £5 per player from the subscription element and attach a copy of your certificate if you have
completed a Club or FA child protection course.
If you have any difficulty in paying these fees, please talk to your child’s team Manager, in confidence.
Signature and declarations
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I and the other members of my family named on this form apply to become members of Cumnor Minors FC for the
2014/15 season. We agree to observe and be bound by the Club’s Rules and Constitution (see
www.cumnorminorsfc.net or ask your team Manager for a copy).
I have received and read a copy of The Cumnor Minors Code. I, my family members and guests agree to abide by it
all times.
I agree to Cumnor Minors FC holding the details provided on this form, league registration and child protection
forms on manual and computerised records, and using them for the Club’s football and related purposes.
I agree to my and my family members’ names and photographs appearing in printed publicity and on the Club’s
website.
I agree to my son/daughter receiving medication as detailed above and emergency dental, medical or surgical
treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
I will inform Cumnor Minors FC promptly of any changes in my or my son/daughter’s medical or other
circumstances during the season.
Parent or guardian’s signature……………………………………….…..
Date…………………………
Please return your form and payment to your team Manager by Saturday 14th September 2014
We will not allow your son/daughter to train or play if any part of this form
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or the subscription element of the fees remains outstanding after this date. The Gift aid part of the
fees is voluntary.
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Gift Aid declaration – for a single donation
Name of charity or Community Amateur Sports Club
CUMNOR MINORS FOOTBALL CLUB
Please treat the enclosed gift of £ 15.00 as a Gift Aid donation.
I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for the
current tax year (6 April to 5 April) that is at least equal to the amount of tax that all the
charities and Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my
gifts for the current tax year. I understand that other taxes such as VAT and Council Tax do
not qualify. I understand the charity will reclaim 25p of tax on every £1 that I have given.
Donor’s details
Title ------------- First name or initial(s) ------------------------------------------------------Age Group--------------------------Surname -------------------------------------------------------------------------------------------Full Home address -------------------------------------------------------------------------------------------------------------------------------------------------Postcode ----------------------Signature ------------------------------------------------------Date ----------------------------Please notify the charity or CASC if you:
Want to cancel this declaration
Change your name or home address
No longer pay sufficient tax on your income and/or capital gains
If you pay Income Tax at the higher or additional rate and want to receive the additional
tax relief due to you, you must include all your Gift Aid donations on your Self Assessment
tax return or ask HM Revenue and Customs to adjust your tax code.
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