Boys Soccer School - August 2021

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This form must be completed for all participants. It must be completed and signed by an authorised adult eg Parent, Guardian, etc

Email *

Dagenham & Redbridge FC Community Trust is a Registered Charity #1141511

PERSONAL INFORMATION RELATING TO THE PARTICIPANT

Please ensure that all information entered is correct.
This MUST be completed by a parent, guardian or responsible adult

Please indicate which weeks you are registering your child for. *

Boys' Soccer Camp 2nd to 6th August

Boys' Soccer Camp 9th to 13th August

Boys' Soccer Camp 16th to 20th August

Boys' Soccer Camp 23rd to 27th August

Required

Payment Details

The cost of each week (5 days) is £40 per child and MUST be paid in advance. Your child's place is not guaranteed until payment has been received. You can pay by cheque, online BACS or cash. Please indicate your method of payment below. You will be contacted as soon as you have registered. NB Payments are not refundable if cancellation is requested after 11th July 2021

How do you wish to pay? *

Cheque (Payable to D&RFC Community Trust)

BACS (Account: D&RFC Community Trust, Number: 19266219 Sort Code: 601115)

Cash

First Name of Child *

Last Name of Child *

Gender of Child *

Female

Male

Prefer not to say

Other:

Date of Birth of Child *

YYYY

School/College/Academy Attended by Child

Which Ethnic Grouping Best Describes Your Child? *

Asian / Asian British / Other Asian background

Black / African / Caribbean / Black British / Other Black background

Mixed / Multiple Ethnicity / Other Mixed or Multiple ethnic background

White British / Irish / Gypsy or Irish Traveller / Other White background

Other ethnic background

Does Your Child* Have Any Disabilities? *

Yes

Prefer Not To Say

If You Answered 'Yes' To The Previous Question Please Give Further Details Below

Does Your Child* Have Any Medical Conditions, Allergies, Illness, Physical Or Learning Disabilities That Should Be Brought To Our Attention? *

Yes

If You Answered 'Yes' To The Previous Question Please Give Further Details Below

CONTACT INFORMATION

Please include as much information as possible. Please ensure that all telephone numbers and email addresses are correct.

Home Address *

Home Postcode *

Home Telephone No

Contact Details for a Child (17 and below) Registration Only

To be completed by a parent, guardian or responsible adult

Mothers Contact Telephone Number

Mother's E-Mail Address

Father's Contact Telephone Number

Father's E-Mail Address

Guardian's Telephone Number

Guardian's E-Mail Address

Other Contact Emergency Telephone Number

Name of Other Contact Emergency Person

CONSENT

Please read all of the information below very carefully and contact the Trust if you are unsure about anything.

From time to time the Trust may take images (photos or video) of the people participating during Trust activities for promotional use by the Club and/or the Trust, including matchday programmes, social media, etc. Do We Have Your Permission To Take And Use Such Images? *

Yes

I give permission for Trust or Club staff to administer First Aid if necessary, and to transfer my child to hospital should an emergency arise. *

Yes

Is There Any Other Information You Think We Might Need?

I wish for my child to be accepted for Trust activities and I agree to the terms, conditions and points indicated above. I confirm that any medical conditions which may affect my child’s participation within the activity have been fully disclosed.

Please add your Full Name and Date in the sections below

Name of Person Completing Form *

Date Form Completed *

YYYY

Dagenham & Redbridge Football Club Community Trust would like to occasionally send you information about new opportunities and activities? If you wish to opt out, please tick below.

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