Family Membership Application Form

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Pontblyddyn CC

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

info@pontblyddyncc.org.uk

Tel: 01352 748460

Pontblyddyn Cricket Club

Family Membership Application Form -2025

2 Adults (spouses/partners) & 2 Juniors

Fees: £100 (one off payment) or 6 monthly direct debit payments of £20 (Total £120)

PLEASE NOTE:

additional junior members may be added after submitting this form by following the link on the next page.

Family Membership Application Form

Lead Member First Name:

Lead Member Surname

Street Address

Town

County

Post Code

Email:

Phone:

Date of birth

Gender

Do you suffer from any of the following

Epilepsy

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

Yes

No

Emergency Contact Name

Emergency Mobile No.

Emergency Work No.

Emergency Home No

Do you consider yourself to have a disability?

Yes

No

If Yes, what is the nature of your 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

Joint Member First Name

Joint Member Surname

Joint Member Email:

Joint Member Phone

Joint Member DOB (required for joint member)

Joint Member Gender (required for joint member)

Do you suffer from any of the following? (optional)

Epilepsy

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 I have provided all the medical information that I feel is relevant in relation to the participation of activities at Pontblyddyn Cricket Club (optional)

Yes

No

Emergency Contact Name

Emergency Mobile No.

Emergency Work No.

Emergency Home No.

Do you consider yourself to have a disability? (optional)

Yes

No

If Yes, what is the nature of your 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

Please note that two junior members / students may be added to this family membership form, any further junior/ student members need to be added to the additional junior family members form (accessible after completion of this from). Please ensure that all the required information is completed for each junior member. Total Number of Junior members in this group

One

Two

Three

Four

More than Four

Junior 1 First Name

Junior 1 Surname

Junior 1 Email (if over 16 only)

Junior 1 Phone (if over 16 only)

Junior 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 are considered 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 ? (1st Named junior player)

Yes

No

Junior 2 First Name

Junior 2 Surname

Junior 2 Email (if over 16 only)

Junior 2 Phone (if over 16 only)

Junior 2 DOB (required for 2nd junior application )

Junior 2 Gender (required for 2nd junior application )

Does the junior applicant suffer from any of the following?

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 are considered 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

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 ? (2nd named junior player)

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.

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Home
About
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Contact
Club Management Committee

Contact info:

01352 748 460

info@pontblyddyncc.org.uk

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Wrexham Road,

Pontblyddyn,

Flintshire.

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