CHELMSFORD HOCKEY CLUB
For Admin Purposes only
School Year
Age Group
Membership Secretary - Kat Hales
C/o 23 Finchley Avenue
Chelmsford
Essex CM2 9BX
07775 774700 - membership@chelmsfordhc.org.uk
2015/2016 JUNIOR NEW MEMBER REGISTRATION AND PARENTAL CONSENT FORM
JUNIOR CONTACT DETAILS
(All fields are required)
Name
Date of Birth
M/F
Address
Membership No
TBA
Place of Birth
Post Code
Home Telephone
Junior Mobile No.
School/College
Junior Email Address
PRIMARY CONTACT (All fields are required)
Parent/Guardian
Mobile No.
Parent Email Address
FURTHER CONTACTS (required in case of emergency) (All fields are required)
2nd Contact
2nd Tel Number
Doctor
Dr Tel Number
Doctors Surgery
Parent(s) Occupation(s) (optional)
Any voluntary “off pitch” skills you can offer to CHC?
(i.e. DIY, coaching, fundraising, recruitment, photography,
website development, accountancy, team manager etc)
KNOWN MEDICAL CONDITIONS, ALLERGIES, MEDICATION (If None, please state “None”)
Email addresses will automatically be added to the club mailing list used for admin and club news only.
Please tick this box if you do not want to receive these mailings.
CONSENT
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I agree to my daughter/son taking part in the activities of the Chelmsford HC, and accept that Chelmsford HC will hold the above details on a secure
database which will be held confidentially, used only for Chelmsford HC purposes and not passed to any third party.
I acknowledge that playing hockey carries a small risk of injury, and that the wearing of shin pads and a gum shield will minimise that risk whilst
training and for matches. If my child does not wear them for any reason I will not hold Chelmsford HC responsible for any injury sustained as a result.
I confirm that to the best of my knowledge my daughter/son does not suffer from any medical condition other than those mentioned above, and that
I will advise the club immediately of any change.
I consent to my daughter/son travelling by any form of public transport, mini-bus or by a motor vehicle (fitted with BS approved seat belts) driven by
a Chelmsford HC official or any other parent/guardian attending an event in which the Club is participating.
In the event that I as a parent/guardian am called upon to assist with transporting players other than my own I confirm that my vehicle will be
covered by appropriate insurance and fitted with seat belts that comply with the appropriate British Standard. I will ensure that seat belts are worn at
all times.
I authorise the leader of the party or any Club official accompanying the party who may be present to consent to such medical treatment (including
inoculations, blood transfusions or surgery) which in the opinion of a qualified medical practitioner may be necessary during any time when my
daughter/son is with Chelmsford HC and away from direct parental control and discretion.
Please state the name of the club member who recommended CHC to you (if applicable)………………………………….………..
I enclose a cheque / have made an online payment (delete as appropriate) for £__________.
SIGNED………………………………………………………………………………………………… Parent/Guardian
NAME…………………………………………………… (Please PRINT name in block capitals)
DATE……………………………
PHOTOGRAPHY / RECORDED IMAGE CONSENT
To be completed by the junior member and the parent
It is possible that photographs or video footage may be taken during Chelmsford Hockey Club (CHC) training or
matches and CHC may use the photographs for feedback purposes and coaching opportunities or for promotional
reasons. As part of our Child Protection Policy we need to obtain the consent of parents / those legally responsible
and the young person prior to taking photos or filming. Please complete the details below.
__________________________________________
To be completed by the junior member
I do/do not* authorise CHC to use the images resulting from any photo / film shoot. This includes any reproductions
or adaptation of the images for all general publicity purposes.
Name (of junior)..................................................... Signature (of junior)......................................................
__________________________________________
To be completed by the parent / person with legal responsibility for the junior member
I do/do not* authorise CHC to use the images resulting from any photo / film shoot. This includes any reproductions
or adaptation of the images for all general publicity purposes.
Name (of parent)................................................... Signature (of parent)......................................................
ETHNICITY & DISABILITY
Whilst it is not compulsory for the following sections to be completed, the paragraph below explains why this personal
information is considered to be important.
Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have existed within sport particularly in relation to gender, race and
disability. Sport England and England Hockey 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 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 develop strategies to ensure that all people have the opportunity in the future to develop and progress in sport.
England Hockey requests this data from clubs as part of the annual affiliation process and completing this data accurately enables the club to give an accurate picture to England Hockey
on our membership.
Ethnicity
Ethnicity
Tick Box
Disability
Tick Box
Tick Box
White British
Asian or Asian British - Pakistani
None
White Irish
Asian or Asian British - Bangladeshi
Deaf
White Other
Asian or Asian British – Other
Visually impaired
Mixed – White and Black Caribbean
Black or Black British – Caribbean
Hearing impaired
Mixed – White and Black African
Black or Black British – African
Physical disability
Mixed – White and Asian
Black or Black British – Other
Learning disability
Mixed – Other
Chinese
Multiple disability
Asian or Asian British - Indian
Other Ethnic Group
CHELMSFORD HOCKEY CLUB
Membership Secretary - Kat Hales
C/o 23 Finchley Avenue
Chelmsford
Essex CM2 9BX
07775 774700 - membership@chelmsfordhc.org.uk
Dear Parent
2015/2016 JUNIOR NEW MEMBER REGISTRATION AND PARENTAL CONSENT FORM
Welcome to the 2015/2016 season with Chelmsford Hockey Club Junior Section, and thank you for your interest in Chelmsford
Hockey Club. In order to ensure that your child is happy to become a member we offer the first three “taster” training sessions
free. Please fill out the attached form before the taster sessions though, as each child must have a signed Parental Consent form,
which this form includes. Once completed and signed, please either send to me at the address above, or present to your child’s
squad manager on your first attendance. Please note all fields should be completed.
Subscriptions: After the three taster sessions, to continue to attend training and take part in matches we require an annual
subscription as shown in the table below.
School Year
Up to and including Year 8
Years 9 to 13
Adult Social Membership
Age
Under 8,9,10,11,12,13
Under 14,15,16,17,18
n/a
SUBSCRIPTION
£65.00
£75.00
£10.00
NB. No training fees or match fees will be collected during the winter season for participation in outdoor junior hockey. The sub is an all
inclusive sum. Junior members aged under 14,15,16,17 & 18 can attend senior midweek training and participate in senior Saturday matches;
those selected to play in adult teams will be expected to pay £6 per adult match played (but no extra subscription).
We prefer all payments by cheque or online. If you pay by cheque, please make out to Chelmsford HC and send the appropriate
subscription to me at the address above. You can also pay online as follows, quoting your child’s name and ‘SUBS’ in the
reference.
Account Name: Chelmsford Hockey Club HICA
Sort Code: 30-91-85
Account No: 00997139
Please remember that without the Parental Consent Form in our possession we reserve the right to exclude your child from
training or matches, as we are not meeting our insurance and child protection duties. Please ensure that you register your child’s
attendance with the manager for each training session or club match, and that you collect your child promptly after each session
attended.
Please be aware that playing hockey carries a small risk of injury, and we strongly recommend the wearing of shin pads and a
gum shield, which will minimise that risk whilst training and for matches.
If you need further information most things are covered on the website (www.chelmsfordhc.org.uk), however if you can’t find
your answer there, don’t despair! Give me a ring or email me and I will do my best to help.
I hope that your child will enjoy their time with us, and will develop a lifetime love of the great sport of Hockey.
Yours sincerely
Kat Hales
Membership Secretary
Please see the reverse of the attached form for a photography consent
form and a request from Sport England and England Hockey concerning
Ethnicity and Disability statistics. Please may we have your help with
this information.