WORCESTERSHIRE
DISABILITY FOOTBALL
CLUB
MEMBERSHIP REGISTRATION FORM
(Please complete in BLOCK CAPITALS)
PLAYER
Surname
Forenames
Known as
Age Next Birthday
Team you Last Played For
GenderDate of Birth
Favoured Playing Position
School (if applicable)
Home Address (including Postcode)
Home telephone Number Mobile telephone number E-Mail Address
PARENT/CARER
Surname
Forenames
Known as
Title
Address (including postcode)
Home telephone Number Mobile telephone number E-Mail Address
ALTERNATE CONTACT
Surname
Forenames
Known as
Title
Home telephone Number Mobile telephone number E-Mail Address
WDFC PLAYER APPLICATION FORM
1
ISSUE 2 (June 2015))
MEDICAL QUESTIONNAIRE
Completed by:
Has the player at any time received an
Anti-Tetanus injection?
(Parent/Guardian/Carer/Player)
If yes, please give approximate date
YES/NO
Is the player 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, including
details of the applicant’s disability (eligibility rules are published at
www.wdfc.org/gpage1.html)
Before signing please read this: I am pleased to allow and agree that the above mentioned player shall attend
training and the playing of games for Worcestershire Disability Football Club, (if under 18 years, including
travelling to away games on designated transport in the care of a qualified adult (FA child safeguarding certificate
and CRB checked)), as agreed within the rule structure of the Football Association and the Club. I am aware that
the full Club Rules can be found at www.wdfc.org. 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 (or the applicant) confirm that I have read and understood the Clubs Rules and Codes of Conduct and I promise
to abide by them.
I agree to the applicant’s 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 and supervised photographs are taken.
Name of Parent/Guardian/Carer/Player (if
over 18
Signature
Date
PLEASE RETURN FORM TO:
Club Secretary, c/o 6 Geraldine Road, Malvern,WR14 3PA or email to [email protected]
(UNDER 18 – Form MUST be signed by Parent/Guardian/Carer)
WDFC PLAYER APPLICATION FORM
2
ISSUE 2 (June 2015))