EAST GRINSTEAD HOCKEY CLUB – 12 to 18 Yrs MEMBERSHIP FORM
Name:
Date of Birth:
Gender: Male / Female
Email:
Address:
Post Code:
Mobile:
Tel. No.:
For 2007/08 our junior membership structure has changed
slightly, please select carefully
Junior Saturday and Sunday, £140.00 - Includes all Saturday and Sunday league matches, published
training, match fees and EGSC membership.
Junior Sunday Only, £40.00 - Includes all Sunday league games, published training, match fees and EGSC
membership. Girls playing occasional Saturday games have the option of paying this membership fee plus
£6 per Saturday game played.
Category
Junior Saturday and Sunday
Junior Sunday Only
Annual Subscription
£140.00
£40.00
Please Tick
Rates all include £12 EGSC membership, which is a prerequisite for EGHC membership. This offers a host
of benefits including discount at the bar and reduced rates on facility hire. If you already pay this through
independent membership, membership of another section or family membership please reduce the amount
listed by £12 and enter your EGSC membership number here:
Amount Payable:
Payment Method
Cheque – payment in full payable to EGSC
Direct Debit – new form attached
Direct Debit –carry on with existing direct debit instructions
Medical Information
Please detail below any important medical information that our coaches or captains should be aware of (e.g.
epilepsy, asthma, diabetes, allergies, injuries etc.)
Emergency Contact Details
First Name
Second Name
GP Name and Surgery
Tel.
Tel.
Tel.
By returning this completed form, I agree to my son/daughter 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 agree to my son/daughter travelling by car driven by a club member or another parent to any event.
 I agree to my son/daughter being photographed for local media and website use.
 I understand that in the event of an injury or illness all reasonable steps will be taken to contact me,
and to deal with that injury/illness appropriately.
Name of parent/carer:
FOR OFFICE USE
MEMBERSHIP NUMBER
Signature of parent/carer:
Date:
CATEGORY
DATE SUBSCRIPTION PAID
Sporting Information
Have you played hockey before? Yes / No
If yes, where have you played the sport: (please indicate below)
 Primary/prep school
 Secondary school
Please State School / Team:
 Local authority coaching session(s)
 Club
 County
 Other (please specify)
Sports Equity Monitoring
Whilst it is not compulsory that this section is completed, the following paragraph explains why it is
important.
Sport can and does play a major role in promoting the inclusion of all groups in society. However,
inequalities have traditionally existed within sport, particularly in relation to gender, race and
disability. Sport England is committed to promoting and developing sports equity, which is about
fairness in sport, equality of access, recognizing inequalities and taking steps to address them. By
monitoring the profile of young 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
together develop strategies to ensure that all young people have the opportunity in the future to
develop and progress in sport.
Ethnicity
In order to help the club monitor its membership, can you please tick one of the following to identify
your ethnic group/origin:
Choose one section from A to E and then circle as appropriate.
A White
British/Irish/Any other white background (please specify):
B Mixed
White & Black Caribbean/White & Black African/White & Asian/Any other mixed background
(please specify):
C Asian or Asian British
Indian/Pakistani/Bangladeshi/Any other Asian background (please specify):
D Black or Black British
Caribbean/African/Any other Black background (please specify):
E Chinese or other ethnic group
Chinese/Any other (Please specify):
Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or
mental impairment, which has a substantial and long-term adverse effect on his or her ability to
carry out normal day-to-day activities’.
Do you consider yourself to have a disability?
Yes / No
If yes, what is the nature of your disability?
Visual impairment / Hearing impairment / Physical disability / Learning disability / Multiple disability
Other (please specify):
Please return post box in East Grinstead Sports Club reception or your team Manager.
FOR OFFICE USE
MEMBERSHIP NUMBER
CATEGORY
DATE SUBSCRIPTION PAID
EGHC U18 - Direct Debit Form
NAME:
SECTION:
Category
Please Circle Required Category
Annual Subscription
Monthly Direct Debit –
payable over 10 months
£140.00
£40.00
£14.00
N/A
Junior Saturday and Sunday
Junior Sunday Only
Single Annual Payment By Direct Debit
If, for convenience, you wish to pay your subscription for membership of East Grinstead Hockey Club by
direct debit in a single annual payment, please complete and submit the DD form below and your payment
will be collected at the start of each season.
Interest Free Payment By Direct Debit Over 10 Months
You may pay your subscription for membership of East Grinstead Hockey Club by Direct Debit on an interest
free basis over 10 months, the monthly amount to be debited being the subscription rate divided by 10, with
the first payment being collected at the start of the season once the DD has been processed. In the event
that you elect to pay by this option, please sign and date the agreement below.
In the event that the Direct Debit is cancelled, or payments are withheld, before the full 10 payments have
been collected then I agree to pay the outstanding balance directly to East Grinstead Sports and Country
Club (to be signed by holder of the direct debit):
Signature:
Date:
DIRECT DEBIT GUARANTEE
This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.
The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.
If the amounts to be paid or the payment dates change, you will be told of this in advance by at least
10 working days, as agreed.
If an error is made, by East Grinstead Sports & Country Club, or by your Bank or Building Society, you are guaranteed a full and immediate refund from your branch of the amount
paid.
You can cancel this Direct Debit at any time by writing to your bank or building society. Please also send a copy of your letter to East Grinstead Sports & Country Club.
Please cut here
INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY DIRECT DEBITS
Please delete as appropriate
Yearly
Please fill in this form and send to: EAST GRINSTEAD SPORTS & COUNTRY CLUB, SAINT HILL ROAD, EAST
GRINSTEAD, RH19 4JU.
1.Name and full postal address of your Bank or Building Society branch.
Originator’s Identification Number
4. Bank or
To: The Manager
Building Society
Account Number
Bank/Building Society
5.Account /Reference Number
Address
6. Instruction to your Bank or Building Society
Please pay East Grinstead Sports & Country Club Direct Debits
from the account detailed on this instruction subject to the
Post Code
safeguards assured by the Direct Debit guarantee.
(As shown above)
EGSCC
2. Name(s) of
Account holder(s)
Signature(s)
3. Branch sort code
(From top right hand
corner of your cheque)
Date
Banks and Building Societies may not accept Direct Debit Instructions from some types of account
FOR OFFICE USE
MEMBERSHIP NUMBER
CATEGORY
DATE SUBSCRIPTION PAID