INTERNAL USE ONLY
Cash / Cheque
Application number:
Date:
CIYMS MINI RUGBY APPLICATION FORM 2014/2015
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CIYMS Mini Rugby Registration for the 2014/15 season will be held on Sat 30 August 2014 at 1000am.
Please complete the form and bring with payment to CIYMS on 30 August 2014.
Please note that player numbers are restricted to 30 players per age group (24 for P2). First preference will
be given to players returning from last season. If other spaces are available for the 2014/2015 season in
any age group, new players will be placed on a waiting list and will be informed of the allocation of a place by
6 September 2014.
PLEASE PRINT ALL INFORMATION ON THIS FORM
FULL NAME OF MINI RUGBY APPLICANT
DOB
AGE AT 01.07.2014
SCHOOL ATTENDED
SCHOOL YEAR FROM SEP 14
NAME OF PARENT/GUARDIAN
FULL POSTAL ADDRESS (inc postcode)
E-MAIL (this will be used as the main means of contact)
HOME TELEPHONE
MOBILE
EMERGENCY CONTACT NAME
RELATIONSHIP TO PLAYER
EMERGENCY HOME TELEPHONE
EMERGENCY MOBILE
DETAILS OF ANY ALLERGIES OR MEDICAL CONDITIONS
DETAILS OF FAMILY DOCTOR (Name and Health Centre/Hospital)
PHOTOGRAPHY DECLARATION I hereby give permission for any photographs taken of the above child during coaching
sessions, inter-club fixtures, Festivals or in conjunction with sponsors, to be used for press and promotional purposes.
SIGNATURE
CODE OF ETHICS DECLARATION I hereby declare that I will abide by the IRFU Code of Ethics for spectators at all mini
rugby events. The Code is available to view or download from www.ciymisminis.com
SIGNATURE
HELPING WITH MINI RUGBY Please circle if you would be interested in helping out at CIYMS Mini Rugby.
Coaching
Organising
Sponsorship
WWW
Latte ladies
CLUB MEMBERSHIP Please circle if you would like information about joining CIYMS RFC as a non-playing member.
Yes
No
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MINI RUGBY FEE FOR 2014/15 SEASON IS £60.00 PER PLAYER.
FEE PER ADDITIONAL PLAYER FROM THE SAME FAMILY IS £40.00.
PLEASE MAKE CHEQUE PAYABLE TO CIYMS RFC AND PLACE YOUR CHILD’S NAME AND AGE GROUP ON THE REVERSE.