Additional Junior Family Membership Application Form

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Home
About
Membership
Club Policies and Safeguarding
Sponsors
Contact
Club Management Committee

info@pontblyddyncc.org.uk

Tel: 01352 961121

Pontblyddyn Cricket Club

Family Membership Application - Additional Juniors - £10 each

PLEASE NOTE: this form if for two additional junior members, if further additional junior members need to be added, please submit this form and then select the link on the following page to access an another form.

Family Membership Additional Juniors

Lead Member First Name

Lead Member Surname

Lead Member DOB

Lead Member Email:

Junior 3 First Name

Junior 3 Surname

Junior 3 Email (if over 16 only)

Junior 3 Phone (if over 16 only)

Junior 3 DOB

Gender

Does the junior applicant suffer from any of the following?

Eliplepsy

Heart Trouble

Asthma / Breathing difficulties

Allergies (details below please)

Other condition (details below)

None

Please enter any additional details of medical conditions or any other medical or medication information that you feel is relevant in the space below

I confirm that all the medical information that I feel is relevant in relation to the participation of activities at Pontblyddyn Cricket Club has been provided.

Yes

No

Emergency Contact Name

Emergency Contact Mobile No:

Is the junior applicant considered to have a disability?

Yes

No

If Yes, what is the nature of the disability?

Visual Impairment

Hearing Impairment

Mobility Impairment

Learning Impairment

Other (please provide details)

Please enter any additional details of disability that you feel is relevant in the space below

CLUB PHOTOGRAPHY / VIDEO CONSENT. As parent or guardian do you consent to the club photographing or videoing the junior member when involved in cricket / club activities in line with the club photography/video policy.

Yes

No

MATCH LIVE STREAMING CONSENT. As a parent or guardian do you consent to video live-streaming or subsequent publication of games in which the named junior player is involved ? (3rd named junior player)

Yes

No

Junior 4 First Name

Junior 4 Surname

Junior 4 Email (if over 16 only)

Junior 4 Phone (if over 16 only)

Junior 4 DOB (required for 4th junior application

Junior 4 Gender (required for 4th junior application)

Does the junior applicant suffer from any of the following? (required for 4th junior application)

Epilelpsy

Heart Trouble

Asthma / Breathing difficulties

Allergies (details below please)

Other Condition (details below)

None

Please enter any additional details of medical conditions or any other medical or medication information that you feel is relevant in the space below

I confirm that all the medical information that I feel is relevant in relation to the participation of activities at Pontblyddyn Cricket Club has been provided. (required for 2nd junior application)

Yes

No

Emergency Contact Name

Emergency Contact Tel No:

Is the junior applicant considered to have a disability? (required for 2nd junior application)

Yes

No

If Yes, what is the nature of the disability?

Visual Impairment

Hearing Impairment

Mobility Impairment

Learning Impairment

Other (please provide details)

Please enter any additional details of disability that you feel is relevant in the space below

CLUB PHOTOGRAPHY / VIDEO CONSENT. As parent or guardian do you consent to the club photographing or videoing the junior member when involved in cricket / club activities in line with the club photography/video policy. (required for 2nd junior application)

Yes

No

CONFIRMATION - As Lead member I confirm that the terms of club membership are accepted by all members within the family group

By accepting the terms of membership, you are providing consent that you have read and understand the club policies and privacy statement and accept them as part of your membership. Any breach of the club rules and or policies will result in disciplinary action being taken, which may result in your membership of the club being revoked.

MATCH LIVE STREAMING CONSENT. As a parent or guardian do you consent to video live-streaming or subsequent publication of games in which the named junior player is involved ? (4th named junior player)

Yes

No

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Home
About
Membership
Club Policies and Safeguarding
Sponsors
Contact
Club Management Committee

Contact info:

01352 961121

info@pontblyddyncc.org.uk

Alder Meadow,

Wrexham Road,

Pontblyddyn,

Flintshire.

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