Worlington Cricket Club Youth Registration and
Parental/Carer Consent Form for Away Fixtures 16-17 winter and summer season.
This form is also to be used when taking young people on away fixtures. One copy should be taken by the team
captain/manager. Worlington Cricket Club (WCC) will use one form per season for all away fixtures. The Home Contact
will be provided with a fixture card and contact details of all Club Officials. The Home Contact will be advised of the club
contact, prior to each away game.
Player: To ensure we have the correct contact details for each player, please insert the information requested below and
return the form to Adam Gallop, or any youth coach or team captain. The form needs to be checked and signed by your
parents or guardian.
Name
Emergency Contact
Name
Home Address
Date of Birth and
school year.
Tel Home
Tel Work
Tel Mobile
E-mail Address
Alternative Contact
Name
Home Address
Tel Home
Tel Work
Tel Mobile
E-mail Address
Doctor’s name and
contact number
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I am aware of the ECB Welfare of Young People guidelines in relation to away fixtures. (A copy of the safe
hands policy is available to view at the clubhouse or on the internet at www.ecb.co.uk/ecb/safeguardingchildren-and-child-protection )
I consent to my child taking part in the activities of the club. I acknowledge that the club will be liable in the
event of any accident only if they have failed to take reasonable steps in their duty of care for my child during
the session.
I agree to be at the pick-up/drop off point at the agreed time.
I agree to my son/daughter travelling to away fixtures.
I understand and accept all rules & regulations set out by Worlington Cricket Club and agree to pay the
subscriptions which cover player insurance. - (All youth players need to be fully paid up members of W.C.C. to
be covered by the clubs insurance when playing).
I have received a copy of the club’s code of conduct and will adhere to it.
I understand that if at any times I have any problems or complaints then I will let the club know in writing as
soon as possible. Any complaints should go to the Child Welfare Officer.
Where possible U16 children will not change at the same time as adults. However, there may be occasions when this is
not possible. I agree to my child sharing changing facilities with adults. Should I wish, I know I am able to supervise their
changing (N.B. This relates to adult fixtures)
Yes/ No
During the season the club will take photographs of teams & players in action. Video recorders may also be used for
coaching purposes. Photographs may be used to publicise activities at the club. Your consent is requested to allow us to
continue with these practices.
Yes / No
Signed – Parent/Carer
Print Name
Date
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Medical Information
1. Does your child experience any conditions requiring medical treatment and /or medication?
Yes
No
If yes please give details
2. Does your child have any allergies?
Yes
No
If yes please give details
3.Does your child have any specific dietary requirements?
Yes
No
If yes please give details
4.Does your child have any disabilities?
Yes
No
If yes please give details
5.Please provide any further information you feel is necessary.
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I confirm to the best of my knowledge that my son/daughter does not suffer from any medical condition other
than those detailed above.
I consent to my child receiving medical treatment which, in the opinion of a qualified medical practitioner, may
be necessary.
I will ensure that If my child needs to carry medication it is brought to each match/training session and that the
coach/manager is made aware
Signed – Parent/Carer
Print Name
Date
Child Welfare Officer
Adam Gallop
Mobile: 07752 704579 Email: [email protected]
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In order for the E.C.B. to monitor membership please can you circle one of the following boxes to identify your ethnic
group?
Ethnicity
A White
 British  Irish
 Any other white background (please specify)
B Mixed
 White & Black Caribbean
 White & Black African
 Any other mixed background (please specify)
C Asian or Asian British
 Indian
 Pakistani
 Bangladeshi
D Black or Black British
 Caribbean
 African
 White & Black Asian
 Any other Asian background (please specify)
 Any other Black Background (please specify)
E Chinese or other ethnic group
 Chinese
 Any other (please specify)
(Sport can and does play a major role in promoting inclusion of all groups in society. However, inequalities have traditionally existed
within sport, particularly in relation to gender, race and disability. The England and Wales Cricket Board and Sport England are
committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and
taking steps to address them. By monitoring the profile of young people in sports clubs, national governing bodies of sport and Sport
England can identify any issues relating to under-representation of different groups and can together develop strategies to ensure all
young people have an opportunity in the future development and progress in sport.)
Official Use Only:
Annual Subs Paid
Yes
No
Received copy of code of conduct
Yes
No
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