<p> Hon Secretary Mr M Barton 39 Sprin Walk Worksop Notts S80 1XQ</p><p>Hon Treasurer Mrs Tracey Bircumshaw 22 Howbeck Lane, Clarborough, Retford, DN22 9LW CLUMBER PARK CRICKET CLUB www.clumberpark.cc Established 1894 Membership Application Form (A form needs to be completed for each member)</p><p>Please complete all pages</p><p>Title: …………….. First Name: Surname: ………………………….. …………………………..</p><p>Address: ...... </p><p>………………………………………………………………………. Post Code: ……………………………</p><p>Telephone Number (inc code): Mobile Number: ………………… ………………………………….. (If junior members parents/carers number) (If junior members parents/carers number)</p><p>Email Address: ……………………………………………………………………………………………….. (If junior members parents/carers number)</p><p>Members Date of Birth: ……………………………. School Year if under 18: …………………...</p><p> I have received, and read and understood the contents of Clumber Park Cricket Club’s photography and the use of video policy statement.  I authorise the use of images as deemed appropriate by the officers of Clumber Park Cricket Club to promote the club and aid the coaching of the following junior member.</p><p>Junior Name Parent/Guardian Signature DISABILITY</p><p>The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial long-term adverse effect on his or her ability to carry out normal day-to-day activities.</p><p>Do you consider yourself to have a disability? Yes  No  If yes, what is the nature of your disability?</p><p>MEDICAL INFORMATION Please detail below any important information that our coaches/junior co-ordinator should be aware of (e.g. epilepsy, asthma, diabetes, allergies etc)</p><p>Does your have any of the following we should be aware of</p><p>Visual impairment  Hearing impairment  Physical disability  Learning disability  Multiple disabilities  Other (please specify):</p><p>SPORTING INFORMATION</p><p>Have you played Cricket before? Yes  No  If yes, where have you played the sport: (please indicate below)</p><p>Primary school  Secondary school  Local authority coaching session(s)  Club  County  Other (please specify):</p><p>2 EMERGENCY CONTACT DETAILS To be completed by the parent/guardian. Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident. Contact name e.g. parent/carer :</p><p>Emergency contact number : </p><p>For types of membership required see attached “Club Membership Fees”</p><p>Membership Type (please tick):</p><p>Senior £60 Colt £45 Junior £40 Kwik/Acorn £20 Social (single) £7.50 Social (joint) £10</p><p>Please make cheques payable to “Clumber Park Cricket Club”. Membership can also be paid direct into the Club account, details needed are: Sort Code 60-24-30, account number 84596112. Please ensure names to which payments refer to are clear. Please also note a membership form still needs to be completed and return to address below.</p><p>I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that I must inform Clumber Park Cricket Club of any changes of address or telephone numbers.</p><p>If there are any members or parents/careers who have skills that would benefit the club and are willing to do so, please contact Michael Beard on 07855 420485 or Owen Jervis on 07900 407804</p><p>Member Signature : Date : (parents/carers if under 18 yr)</p><p>Please return the whole completed form and payment to: Caroline Ball Membership Secretary 2 Devonshire Street Worksop Notts S80 1NA</p><p>The information you provided will only be used for club purposes</p><p>3 Thank you for your Clumber Park Cricket Club Membership ------CLUMBER PARK CRICKET CLUB USE ONLY</p><p>Membership Card Membershi £ Total Date Date Coach Number + Date issued p Cash/Ch Receive Passed name Type q d to Coach</p><p>4</p>