Youth Membership

£70.00 / year

Junior / Mini Membership Secretary : Steve Blanthorn

email : steveblanthorn@bhrfc.co.uk

Tel: 07894 082038

Data Protection Act 1984 – To facilitate the provision of information and newsletters to our members all details given below will be recorded on a database. This is not used for any other purpose
nor will it be so used without your prior consent. Should you have any objection to such a record being maintained you are entitled to request exclusion by writing to the Club Secretary.

One form per player

Players Full Name *

Address *

Post Code *

D.O.B: *

Age on 01/09/2017 *

School Year: *

Photo ID: *

Please upload a passport style photo, not more than 6 months old, taken against a plain background, clear and in focus. 80% of the image should be of the player’s face.

Example:

(max file size 32 MB)

School the player attends: *

Applying Parent / Guardian: *

Parents D.O.B *

Home Telephone: *

Mobile: *

Parents / Guardians Email: *

Previous Rugby Experience: *

Video *

Internet: *

Ethnic Origin (Required for RFU registration) *

Name & Address of Family Doctor *

Doctors Tel Number *

Emergency Contact (1) Name & Number *

Emergency Contact (2) Name & Number *

Has your child had any of the following? Asthma or Bronchitis *

(We will administer supplied inhalers with your written permission. Please label any medication clearly with child’s name)

Heart Condition *

Fits, Fainting or Blackouts *

Severe Headaches *

Diabetes *

Allergies to any known drugs or medication *

Any other allergies e.g. material, food, insect bites etc. *

(We will administer supplied EpiPens with your written permission. Please label any medication clearly with child’s name)

Other Illness or disability *

Any recent contact with contagious diseases or infection *

Has your child received vaccination against TETANUS within the last five years? *

SKU: youth-mship Category:

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