junior membership application
form 2014-2015
We are very pleased to welcome you to Lisburn City Paddlers Kayak & Canoe Club.
Junior membership applies to those applicants under 18 prior to 1st Oct 2014.
Please return the completed junior application form and fee to the Club Secretary:
Lisburn City Paddlers
c/o Brian Carson
10 Cottage Gardens
Lisburn
BT28 3HU
MEMBERSHIP
Are you an individual member of CANI?
Yes/No
If yes please state CANI membership number ______________________________
Please note there is a discounted rate for CANI members. If you are not a member of
CANI the additional charge will provide you with CANI affiliated membership (which
includes 3rd party insurance) until 1st October 2015.
Please make cheques payable to 'Lisburn City Paddlers'
Junior (incl. CANI Affiliation)
£15 [ ]
Junior (CANI member)
£12 [ ]
Please ensure your parent/carer has signed the completed form before it is returned. We
will also use this information to ensure that you are kept informed about club events.
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junior membership application
form 2014-2015
Dear Parent/Carer
Anything written on this form will be held in confidence. Our coaches need to know
these details in order to meet the specific needs of your child.
Junior member’s Full Name:
Address:
Home Tel No:
Mobile :
Email Address:
Age:
Date of Birth:
Gender:
Male
Next of Kin:
Name of any friend/relative
already attending the club
Emergency Contact Name:
Emergency Tel Numbers:
Home:
Mobile:
If unavailable contact
(over 18 only please)
Name:
Tel:
Relationship to child:
GP/Doctor’s Name:
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Female
junior membership application
form 2014-2015
GP/Doctor’s Tel No:
Details of any known special
dietary requirement, allergies,
disability or medical
conditions
Please provide a brief
description of the effects of
your disability or medical
condition and of any particular
needs you may have.
Any other special needs,
requirements or directions
that would be helpful for the
coaches to know about.
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junior membership application
form 2014-2015
PADDLING DETAILS/ EXPERIENCE
Please indicate your level:
Beginner:
Intermediate:
Advanced:
(None, Paddlesport, 1 or 2 Star)
(3 Star)
(4 Star River Leader +)



Star awards only act as a guide you may have no stars and be an intermediate or
advanced paddler.
Can you swim a minimum of 50 metres?
Yes / No
(This is for our information only. An ability to swim is not a necessity as buoyancy aids
are worn at all times)
Which, (if any) BCU star or Paddlesport awards do you have?
Do you hold any BCU coaching awards?
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junior membership application
form 2014-2015
PARENT/CARER STATEMENT
I will inform the coaches of any important changes to my child’s health, medication or
needs and also of any changes to our address or phone numbers given. In the event of
illness, having parental responsibility for the above named child, I give permission for
medical treatment to be administered where considered necessary by a nominated first
aider, or by suitably qualified medical practitioners. If I cannot be contacted and my
child should require emergency hospital treatment, I authorise a qualified medical
practitioner to provide emergency treatment or medication.
I have been made aware that Lisburn City Paddlers have developed a
Safeguarding policy and they are committed to ensuring the safety of my child
by having:

A coach’s Code of Conduct

Clear Recruitment Policy which includes vetting of all coaches and volunteers

A Transport Policy

A Photography Policy

An Anti-bullying Policy

Disciplinary Procedures

A designated person for child protection

Guidelines on Confidentiality
All forms, guidelines and club policies can be found on the official club web site @
www.lisburncitypaddlers.co.uk.
Lisburn City Paddlers are committed to ensuring that any information gathered in
relation to our youth teams meets the specific responsibilities as set out in the Data
Protection Act 1998.
Lisburn City Paddlers coach/development officer will store the above information on
their youth team’s data base for a maximum of 12 months before re-registering the
paddler if still associated with the club.
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junior membership application
form 2014-2015
I confirm that all details are correct to the best of my knowledge and I am able to give
parental consent* for my child to participate in and travel to all activities. By returning
this completed form, I agree to my son/daughter/child in my care taking part in the
activities of the club.
I understand that I will be kept informed of these activities – for example timing and
transport details.
I understand in the event of injury or illness all reasonable steps will be taken to contact
me, and to deal with that injury/illness appropriately.
* Parental consent is defined by the children (NI) Order 1995 Article 6 (I)
Natural mother always has parental responsibility.
Natural father gains parental responsibility:
 If married to the mother at the time of birth or subsequently marries her
 Through an agreement witnessed by solicitor or a Parental responsibility Order
 Post 15 April 2002 if they jointly register the baby’s birth
(This consent will remain valid for one year)
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junior membership application
form 2014-2015
DECLARATIONS
1.) I acknowledge that canoeing is an extreme sport undertaken at my child’s own risk I can
confirm they do not suffer from any disability or medical condition that may render them unfit for
strenuous exercise.* I understand that Lisburn City Paddlers cannot be held responsible or liable
for any personal injury loss or damage as a result of my child’s participation in any club event
except that which is the result of gross negligence and/or wilful or wanton misconduct.
2.) Please tick this box [ ] if you do not agree to Lisburn City Paddlers taking photographs of
your child, which will remain the property of Lisburn City Paddlers and may be used for
promotional purposes.
* Should a medical condition exist this will not necessarily preclude your child from membership
participation but it must be declared. Should you be in any doubt advice should be sought from
your family Doctor
I HAVE READ AND UNDERSTAND THE DECLARATIONS
Signature of Child:
Signature of Parent/Carer:
__________________________
__________________________
Print Name (Parent/Carer): __________________________
Date:
__________________________
Please return this form together with fee as shown on page 1
Has a CANI affiliated membership form completed? (See below)
If “No” has one been previously submitted to LCP?
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Yes/no
Yes/no
junior membership application
form 2014-2015
Left intentionally blank
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junior membership application
form 2014-2015
CANI Affiliated Membership Form
Please do not complete if you are a full CANI member
Have you been a CANI Member before?
If so please supply previous number
Yes/No
BCU/NI/.........../.........../.......
I agree to be bound by the rules and regulations of the association and the British Canoe
Union. I accept liability for my/our share (£1) in the company in the event of liquidation
of the Union.
Signed:
Date:
If signing for under 18’s - Forms must only be signed by the parent or guardian that holds parental
responsibility for the child named above.
Office use
BCU/NI/.........../.........../20
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junior membership application
form 2014-2015
Equality Monitoring
Do not complete if you have previously submitted an equality monitoring form or CANI
affiliated membership form to LCP. (Existing members will have already submitted an equality
monitoring form during previous applications).
Please tick the boxes that are relevant to you. All information collected will be stored within the
data protection guide lines.
GENDER
1. Male

2. Female
3. Not Disclosed

NATIONAL IDENTITY
What do you consider your national identity to be?
1.
Northern Irish

2.
British

3.
Irish

4.
Chinese

5.
French
6.
7.
8.
Polish

9.
Ukrainian

10.
Portuguese

11.
Other
Please Specify


Latvian

_________________________
Lithuanian

ETHNIC ORIGIN
12.
Not Disclosed

To which of these ethnic groups do you consider you belong?
(Please select the option that is most appropriate for you)
1.
White

2.
Chinese

3.
Irish Traveller

4.
Indian

5.
Pakistani

6.
Bangladeshi

7.
Black Caribbean

8.
Black African

9.
Black Other

10.
Mixed Ethnic Group
Please Specify
___________________
Any Other Ethnic Group
Please Specify
___________________
Not Disclosed

11.
12.
10



junior membership application
form 2014-2015
COMMUNITY BACKGROUND
Please indicate your community background by ticking the appropriate box.
1. I am a member of the Protestant community

2. I am a member of the Roman Catholic community

3. I am member of neither the Protestant nor Roman Catholic community

4. Not Disclosed

DISABILITY or MEDICAL CONDITION
Do you consider yourself to have a disability or medical condition?
Yes 
No 
If yes, what is the nature of your disability?
Physical Disability

Learning Disability

Deaf or Hard of Hearing

Mental Health Difficulty

Blind

Autistic

Visually Impaired

Wheelchair User

Other (please specify):
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