Junior 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

Junior Membership Application Form -2025 Under 18s

Fees: £50(one off payment) or 6 monthly direct debit payments of £10 (Total £60)

Junior Membership Application Form

First Name:

Surname

Street Address

Town

County

Post Code

Email: (if over 16 only)

Phone: (if over 16 only)

Date of birth

Gender

Parent / Guardian First Name

Parent / Guardian Surname

Parent / Guardian Address if different

Parent / Guardian email address:

Parent / Guardian Mobile No

Parent / Guardian Home Tel.

Does the junior applicant suffer from any of the following?

Epilepsy

Heart Trouble

Asthma / Breathing dificulties

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 if Different to Parent / Guardian

Emergency Mobile No. (if different to Parent /Guardian

Emergency Work No.

Emergency Home 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

Yes

No

Acceptance of the club terms of membership

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
Membership
Club Policies and Safeguarding
Sponsors
Contact
Club Management Committee

Contact info:

01352 748 460

info@pontblyddyncc.org.uk

Alder Meadow,

Wrexham Road,

Pontblyddyn,

Flintshire.

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