D & R F C Community Trust Registration & Consent Form PL Kicks (Girls)/London United September 2021.
This form must be completed by all participants. NB If the participant is aged 17 or under it must be completed and signed by an authorised adult eg Parent, Guardian, etc (*Delete as appropriate)
Sign in to Google to save your progress. Learn more
Email *
Dagenham & Redbridge FC Community Trust is a Registered Charity #1141511
Select Preferred Group *
PERSONAL INFORMATION RELATING TO THE PARTICIPANT
Please ensure that all information entered is correct.
For a child ie under 18, this MUST be completed by a parent, guardian or responsible adult
Which Activities Are You Registering For?
First Name *
Last Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
School/College/Academy Attended (if applicable)
Which Ethnic Grouping Best Describes You? *
Do You/Your Child* Have Any Disabilities? *
If You Answered 'Yes' To The Previous Question Please Give Further Details Below
Do You/Your Child* Have Any Medical Conditions, Allergies, Illness, Physical Or Learning Disabilities That Should Be Brought To Our Attention? *
If You Answered 'Yes' To The Previous Question Please Give Further Details Below
Dietary Requirements *
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
Additional Contact Details for an Adult (18 and above) Registration Only
(if applying for a child move onto the 'Child' section below)
Adult Mobile Number
Adult Work Number
Adult E-Mail Address (Personal)
Adult Emergency Contact Name
Adult Emergency Contact Number
Additional 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? *
I give permission for Trust or Club staff to administer First Aid if necessary, and to transfer me/my child* to hospital should an emergency arise. *
Is There Any Other Information You Think We Might Need?
I wish for my child/me* 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 me/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 *
MM
/
DD
/
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Dagenham & Redbridge FC Community Trust. Report Abuse
Google Forms