<p> Membership, Parental Consent, Medical & Subscription Details 2011/2012</p><p>We are very pleased to welcome you to Isca Hockey Club. To ensure that we have the correct contact details for you, for insurance, medical and competition eligibility purposes, please complete the information requested below and return the form, together with a cheque if appropriate, to: Rowena Lanyon, 4 Taw Vale Terrace, Station Road, Crediton, EX17 3BU. The Club uses e-mail to keep members informed of club events, so please let us have your e-mail address. This information will be recorded on the Club’s Players’ Register and will only be used for Club communication, management and for emergency contact of members where required. All use will be subject to the Data Protection Act 1998. </p><p>PERSONAL DETAILS If you are under 18 please ask a parent or guardian to complete and sign this form before it is returned. First Name Telephone No. (Home) ……………………………………………… ………………………….…………………… Last Name Tel No. (Member’s Mobile) ……………………………………………… …………………………….………………… Address Tel No. (Parent’s Mobile if U18) ……………………………………………… …………………………….………………… Email (Member) (PLEASE PRINT CAREFULLY) …………………………….………………… Email (Parent/Guardian if U18) ……………………………………………… (PLEASE PRINT CAREFULLY) …………………………….…………………. Town/City Date of Birth (dd/mm/yyyy) ……………………………………………… ...... / ...... / ………… Postcode Gender Male Female ……………………………………… □ □ Do you have an Umpire or Coach Qualification? If yes, please state Do you have: which, the level, registration number and name of professional awarding Yes No organisation. If no, please indicate if you wish to enrol on an umpiring A Current First Aid Certificate □ □ or coaching course Do you have: Yes No ………………………………………………………………………….. An England Hockey CRB Disclosure □ □</p><p>MEMBERSHIP TYPE & SUBSCRIPTION (Please indicate with ) For your correct category see Explanatory Notes attached or on the Website www.iscahockey.co.uk or contact Rowena Lanyon [email protected] for further help Adult (in employment) £299 Youth (14 – 16) £200 (16 and over) (Full Payment by 1st Oct: £279) □ (Playing in Adult matches) (Full Payment by 1st Oct: £185) □ Adult Goalkeeper £185 Youth Goalkeeper (14 – 16) £185 (16 and over with own kit) (Full Payment by 1st Oct: £170) □ (Playing in Adult matches without own kit) (Full Payment by 1st Oct: £175) □ Full-time Student/Apprentice £225 Youth & F/T Student Goalkeepers (14-18) £120 (18 and over) (Full Payment by 1st Oct: £210) □ (Playing in Adult matches with own kit) (Full Payment by 10th Oct: £110) □ Full-time Student/Apprentice £210 Youth (14 – 16) £75 (16 - 18) (Full Payment by 1st Oct: £195) □ (Not playing in Adult matches) □ Full-time Student G’ keeper £130 Junior (6 – 14 Coaching & Training only) £75 (18 and over with own kit) (Full Payment by 1st Oct: £120) □ Full Season Subscription □ Occasional Player £10 Junior (6 – 14 Coaching & Training only) (Adult or Student 16 and £4 per Session (+ £12 match fee) Paying per Session over) □ □</p><p>PAYMENT METHOD (See detailed guide attached or on the Website www.iscahockey.co.uk Please indicate your chosen method of payment. Cheques are to be made payable to ‘Isca Hockey Club’</p><p>Full Amount by Cheque □ Standing Order* □ Date of 1st Payment / / / Internet Bank Transfer □ </p><p>*6 equal payments by standing order must be in place by 1st October. Payment by standing order does not attract the early payment discount. </p><p>CURRENT MEDICAL CONDITIONS Please enter any known current medical conditions including known allergies or any other factors</p><p>…………………………………………………………………………………………………………………………………………………………………</p><p>EMERGENCY CONTACT DETAILS Family Doctor: Full Name Tel No. ………………………………..……………………………………………………... …………………………... Contact 1: Full Name Relationship to Member Tel No. ……………………………….. …………………………. …………………………... Contact 2: Full Name Relationship to Member Tel No. ……………………………….. …………………………. …………………………... PARENTAL/GUARDIAN CONSENT (Under 18 members only)  I agree to my child taking part in Isca Hockey Club activities (coaching, training, matches etc.)  I confirm that, to the best of my knowledge, my child does not suffer from any medical condition other than those stated above.  I consent to my child travelling by any form of public transport, by minibus or by motor vehicle driven by an adult member of Isca Hockey Club or by another parent attending the activity.  I authorise the leader of the party, or any other adult accompanying the party who may be present, to consent to such medical or dental treatment (including inoculations, blood transfusion or surgery) which, in the opinion of a qualified medical practitioner or dental surgeon, may be necessary during any period of time when my child is away on Isca Hockey Club business and away from direct parental control and direction.  I consent to the taking of photographs/digital images of my child during Club activities and for the images naming my child to be used on the Club’s Website and where appropriate for use in press coverage and for coaching purposes.  The Club’s full policies can be read on the Club Website www.iscahockey.co.uk </p><p>Signed: ……………………………………………………. Date: …………………………………………………..</p><p>DECLARATION (Over 18 members only)  I confirm that, to the best of my knowledge, all the above details are correct and that I will inform the Club Membership Secretary of any changes during the season</p><p>Signed: ……………………………………………………. Date: ………………………………………………….. SPORTS EQUITY MONITORING (FOR NEW MEMBERS ONLY) 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, recognising inequalities and taking steps to address them. By monitoring the profile of young people in sports clubs, national governing bodies of sport, 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 boxes to identify your ethnic group/origin: Choose one section from A to E and then tick the appropriate box. A White Any other white background British Irish □ □ (please specify): □ ………………………….. B Mixed White & Black Caribbean □ White & Black African □ Any other Mixed background White & Asian □ (please specify): □ ………………………………… C Asian or Asian British Indian □ Pakistani □ Any other Asian background Bangladeshi □ (please specify): □ ………………………………… D Black or Black British Any other Black background Caribbean African □ □ (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? If yes, what is the nature of your disability? Yes □ No □ Visual Impairment □ Hearing Impairment □ Physical Disability □ Learning Disability Multiple Disability Other (please specify): □ □ □ ………………………………… Sporting Information Have you played hockey before? If yes, where have you played? (tick as many as appropriate) Yes □ No □ Primary School □ Secondary School □ Local Authority Coaching Sessions □ Club □ County □ Other (please specify): □ ………………………………… </p>