AFC Portchester Membership
MEMBERSHIP AND CONSENT FORM – To be completed for any player under 18 years old.
The direct debit form must also be completed before your child can be registered. Please do
not complete this form for the same player twice and please check you have selected the
correct team as some managers have more than one. Thank you.
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Childs First Name *
Childs Surname *
Child’s FA Number (FAN)
Childs Date of Birth *
MM
/
DD
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YYYY
Place of Birth *
Team *
Home Address *
Post Code *
Medical Details *
Please indicate if your child has any medical conditions we should be aware of (e.g. asthma). Include details of any known allergies and all current medication:
Emergency Parent/Carer Details 1 *
Required
First Name *
Last Name *
Parent/carer’s date of birth *
MM
/
DD
/
YYYY
Parent/carer’s FAN number
Emergency Contact No *
Email Address *
Confirm Email Address *
Emergency Parent/Carer Details 2 *
In the event that the above named person cannot be reached, please give an extra emergency contact name and number:
Required
First Name *
Last Name *
Emergency Contact No *
Parent/carer’s FAN number
Parent/carer’s date of birth *
MM
/
DD
/
YYYY
Parent/carer’s email address *
Parent/Guardian Signed *
I have seen AFC Portchester’s Code of Conduct.  Having read the Code I agree to abide by it. I agree that my child will behave in accordance with the club’s disciplinary procedures and code of conduct. I give permission for my son/daughter to have their picture displayed on the AFC Portchester website for advertisement and promotional purposes.  In the event that my child is injured whilst playing football/travelling to and from football events and I cannot be contacted on the above number, I hereby give my consent for my child to receive medical attention.  I agree that the club can use my contact details to keep me informed about events and activities which may be of interest.
Required
Player Signed *
I have understood and will abide by the club’s rules and procedures.
Required
Date Signed *
MM
/
DD
/
YYYY
Data Protection *
I confirm that I have read, understood, and agree to the AFC Portchester Youth Privacy Policy (Click here to view - http://www.afcportchesteryouth.co.uk/news/117-privacy-policy)
Required
All monthly subscriptions will be collected by Direct Debit.

Please use the following link to set it up: 


It's £20 a month starting 1st Dec for 5 months.
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