Section 1: Your Contact Information

Cheltenham Civil Ladies Hockey Club Service MEMBERSHIP FORM

We are very pleased to welcome you to Cheltenham Civil Service Ladies Hockey Club for the 2011-2012 season.

All existing and prospective members are required to complete this membership form and return it with payment prior to selection for league games. In applying for membership, you confirm that you will abide by the Club’s Constitution, Codes of Conduct and Rules which are available online at http://www.pitchero.com/clubs/cheltenhamcivilservicehockeyclub/?primary=aboutus&secondary=clubdocuments . SECTION 1: YOUR CONTACT INFORMATION

FULL NAME

ADDRESS 1

ADDRESS 2

TOWN POST CODE

MOBILE HOME PHONE

EMAIL SHIRT NUMBER DATE OF BIRTH (returning

SECTION 2: MEMBERSHIP TYPE

I am employed as a civil servant or qualify for Family I am not a civil servant and need to apply for CACCSA CSSC membership through a spouse or parents. Associate membership (Add column A + B for full fees)

A. B. Please MEMBERSHIP CATEGORIES CCSLHC CACSSA select with Subscription Associate a X below Fees Fees SENIOR Full Senior Membership (Match fees £10 after each match) £30 £25 MEMBER YOUNG Full time students and U16's playing Senior Club Matches (Match £30 £5 MEMBER fees £5) SOCIAL For non playing parents & friends of the Club £5 n/a MEMBER TRAINING ONLY Pay £2 at each training session† n/a n/a

All cheques to be made payable to CCSLHC. Please be sure to pay your subs before the 18th September 2011. The Club Constitution and Women’s West League rules state that subscription fees have to be paid before players are eligible to participate in league games. Players will not be entitled to play in Club matches if subscriptions remain unpaid after this date. Please contact Emma Crowe, the Club Treasurer at [email protected] if you have any queries.

SECTION 3: MEDICAL INFORMATION & CONSENT

In case of emergency and as part of the Club’s responsibility to its members, All club members are required to complete this medical information section as accurately as possible. Details will be held securely with access restricted to authorised club officers only. EMERGENCY CONTACT RELATIONSHIP TO YOU CONTACT PHONE NO. For example: Asthma, Diabetes, Allergies, Medication you are taking, Current or previous relevant injuries.

IMPORTANT MEDICAL INFO

I declare myself to be physically fit and capable of full participation. In the event that I am injured, I give my permission for the coaches/ first aiders/ officials appointed by CCSLHC to obtain emergency medical DECLARATION treatment on my behalf. I agree to notify the Club ASAP of any changes to the information provided (Parents/guardians for Under 18’s will need to confirmation of this in Section 5). SIGNATURE DATE SECTION 4: CLUB DEVELOPMENT (Any info you provide will be used for club development purposes only)

The following information is helpful for our records especially when applying for accreditation and/or funds to help our club and is used on a group aggregate basis so your specific details are never shared. Other information is used for internal Club purposes only.

4.1 ETHNICITY (mark with an X) 4.3 Please state if you hold any applicable qualifications: White British  Irish  Other  Coaching Mixed: White & Black Caribbean  White & Black African  Umpiring Mixed: White & Asian  Other  First Aid Asian: Indian  Pakistani  Bangladeshi  Other  Child protection Black: Caribbean  African  Other  PE Qualifications Chinese  Other Other  4.2 Do you have any disabilities? 4.4 I hold an up to date CRB check issued through:

4.5 We encourage members to be actively involved in the running of our club. Please indicate areas if there are any areas in which you have experience that may benefit the Club. Please also indicate if you would like to get involved in certain areas even if you may have little or no experience (e.g. coaching, umpiring, committee roles, qualified first aider, web design, planning, fundraising, etc):

SECTION 5: UNDER 18 MEMBERS (**TO BE COMPLETED BY PARENT/GUARDIAN**)

It is a Club requirement and England Hockey policy that parental consent is provided for members under the age of 18 for participation, transportation and photography purpose. Further details can be found in the CCSLHC Code of Conduct and Safeguarding and Protecting Young People in Hockey policies available in the club handbook.

Please can you read the following statements carefully and indicate your option by deleting the non appropriate highlighted phrase.

5.1) I agree / do not agree to my daughter playing in adult hockey matches.

5.2) I confirm/ do not confirm that my daughter is fit to play hockey and that all relevant medical information provided in section 3 is correct and accurate.

5.3) In the event of an emergency where I as the parent/guardian cannot be contacted, I agree/ do not agree that a responsible adult be allowed to accompany my child to receive professional medical attention and if appropriate to sign medical consent forms.

5.4) I do / I do not consent to my daughter travelling to venues for matches and training by transport organised by the club which may include travelling in other players’ private cars.

5.5) I agree / do not agree to my daughter being photographed as part of a team record. (NB. It is not always possible to control photography by external parties however this approval is for publicity and training use by CCS LHC officials and publicity of the club including local newspapers, local magazines and CCS LHC website)

SIGNATURE DATE

RELATIONSHIP

THANK YOU FOR COMPLETING THIS FORM.

Please make cheques payable to CCSLHC Please send your completed form and payment to Caroline Purnell, 7a Suffolk Street, Cheltenham, GL50 2DH. You can alternatively email the membership form to [email protected] and hand payment to your captain at training. Cheltenham Civil Service Ladies Hockey Club is committed to safeguarding the privacy of our members. Our Privacy Policy statement explains the data processing practices of CCS LHC. If you have any requests concerning your personal information or any queries with regard to these practices please contact a member of the Committee.