Membership Form
City of Bath Hockey Club
MEMBER CONTACT INFORMATION
TITLE
Mr/Mrs/Miss/Ms (Please circle or state other):
FIRST NAME
ADDRESS 1
LAST NAME
ADDRESS 2
D.O.B.
CITY
MOBILE
COUNTY
EMAIL
POST CODE
MEMBERSHIP TYPE
MEMBER TYPE
DESCRIPTION
ADULT
Over 25 on 1st September
U25
Over 18 but Under 25 on 1st September
JUNIOR
Under 18 on 1st September
GOALKEEPER
All Ages
SUMMER LEAGUE
All Ages
NON-PLAYING
For non-playing members, parents & friends of Club
MEDICAL INFORMATION & CONSENT (to be completed by PARENT or GUARDIAN if U18)
NEXT OF KIN
DOCTOR
PHONE
PHONE
As far as you are aware, are you allergic to any drugs?
Are you taking any regular medication & for what reason?
Do you have any long-term illnesses or injuries?
DECLARATION: I consider myself/my child to be physically fit and capable of full participation and agree to notify the club of any
changes to the medical information provided. Furthermore, in the event that I am injured I give permission for the officers
appointed by City of Bath Hockey Club to obtain emergency medical treatment on my/my child’s behalf.
NAME
RELATIONSHIP
(if member Under 18)
SIGNATURE
DATE
All details will be kept in a secure database with access restricted to authorised Club Officers only.
City of Bath Hockey Club is an equal opportunities club and answers to the above questions will in no way effect selection.
For further details please read the City of Bath Hockey Club Equality Policy.
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Membership Form
City of Bath Hockey Club
ETHNICITY
DESCRIPTION
PLEASE TICK
DESCRIPTION
White British
Asian/Asian British - Pakistani
White Irish
Asian/Asian British - Bangladeshi
White Other
Asian/Asian British - Other
Mixed - White & Black Caribbean
Black/Black British - Caribbean
Mixed - White & Black African
Black/Black British - African
Mixed - White & Asian
Black/Black British - Other
Mixed - Other
Chinese
Asian/Asian British - Indian
Other Ethnic Group
PLEASE TICK
DISABILITY
DESCRIPTION
PLEASE TICK
COMMENTS
Deaf
Visually impaired
Hearing impaired
Physical disability
Learning disability
Multiple disability
MEMBERSHIP CONSENT (to be completed by PARENT or GUARDIAN if Under 18)
DECLARATION: I confirm that I, the undersigned, hereby give consent that I/my child may participate in designated City of Bath
Hockey Club matches, training sessions and tournaments. I consider myself/my child to be physically fit, capable of full participation
and agree to notify the club of any changes to the medical information provided. Furthermore, in the event of injury, I give
permission for the officers appointed by City of Bath Hockey Club to obtain emergency medical treatment on my/my child’s behalf.
TRANSPORTATION: I consent that I/my child may travel to matches, training sessions and tournaments in transport provided by the
Club, which may include travelling in other member’s private cars.
PHOTOGRAPHY: There are times when images/footage maybe taken of myself/my child during matches and training sessions by
approved agents or officers of the Club. Such images/footage shall only be used in accordance with the City of Bath Hockey Club
Child Protection Policy and I hereby grant the right to use of any resulting images/footage, including any reproductions or
adaptations.
NAME
RELATIONSHIP
(if member Under 18)
SIGNATURE
DATE
All details will be kept in a secure database with access restricted to authorised Club Officers only.
City of Bath Hockey Club is an equal opportunities club and answers to the above questions will in no way effect selection.
For further details please read the City of Bath Hockey Club Equality Policy.
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