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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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* Indicates required question
Childs First Name
*
Your answer
Childs Surname
*
Your answer
Child’s FA Number (FAN)
Your answer
Childs Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth
*
Your answer
Team
*
Choose
U7 Vikings - Darren Lambe
Home Address
*
Your answer
Post Code
*
Your answer
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:
Your answer
Emergency Parent/Carer Details 1
*
Mr
Mrs
Ms
Other:
Required
First Name
*
Your answer
Last Name
*
Your answer
Parent/carer’s date of birth
*
MM
/
DD
/
YYYY
Parent/carer’s FAN number
Your answer
Emergency Contact No
*
Your answer
Email Address
*
Your answer
Confirm Email Address
*
Your answer
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:
Mr
Mrs
Ms
Other:
Required
First Name
*
Your answer
Last Name
*
Your answer
Emergency Contact No
*
Your answer
Parent/carer’s FAN number
Your answer
Parent/carer’s date of birth
*
MM
/
DD
/
YYYY
Parent/carer’s email address
*
Your answer
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.
Yes
Required
Player Signed
*
I have understood and will abide by the club’s rules and procedures.
Yes
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
)
Yes
Required
All monthly subscriptions will be collected by Direct Debit.
Please use the following link to set it up:
https://pay.gocardless.com/AL0013JE9P6NJN
It's £20 a month starting 1st Dec for 5 months.
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