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Team
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Contact Us

[email protected]
01423 752828

Football Registration Form

Name of child/young person

Date of Birth

Address

Gender

Male Female Non-binary Another description (please state below)

Other gender description (if selected above)

Are there any activities in which your child cannot participate?

No Yes (please state below)

Activities in which your child cannot participate (if Yes selected above)

Parent or guardian name

Contact number(s)

Name of alternative adult to contact in an emergency - PERSON 1

Relationship to young person

Contact number(s) of alternative adult

Name of alternative adult to contact in an emergency - PERSON 2

Relationship to young person

Contact number(s) of alternative adult

Are there any specific medical conditions requiring medical treatment?

No Yes (please give details below)

Details of medication required (e.g. pills, inhaler)

Are there any other medical conditions or disabilities to be aware of?

No Yes (please give details blow)

Medical conditions or disabilities (if Yes selected above)

Do they have any allergies?

No Yes (please give details blow)

Allergies (if Yes selected above)

I give my consent that if an emergency medical situation arises, the organisation / club may act in loco parentis for administration of first aid and/or other medical treatment that in the opinion of a qualified medical practitioner may be necessary. I also understand that in such circumstances all reasonable steps will be taken.

I confirm that I have read, or been made aware of, the organisation’s policies on photography, videoing, texting and use of social media.

I confirm that my child is aware of The HIA code of conduct for children and its anti-bullying policy.

I confirm that I am happy for my child is to take part in this activity.

Type name of parent of guardian

Today's date

I give permission for my child’s photograph to be used within printed publications.

I give permission for my child’s photograph to be used on the association’s website.

I give permission for my child’s photograph to be used on the club’s social media channels.

I give permission for video of my child to be used on the association’s website.

I give permission for video of my child to be used on the association’s social media channels

I give permission for video of my child to be used for training or analysis purposes and that the association may retain the images for future use.

I confirm that I have read, or been made aware of, how these images or videos will be stored within the organisation.

Today's date

Type name of parent of guardian

In accordance with our safeguarding policy, we will not knowingly permit direct photographs, video or other images of young people to be taken without consent*. If the child is under 16, consent must be obtained from a parent / carer. *Due to the nature of the sport, young people may be indirectly being in the shot of a photo or video/livestream of an event.

The HIA will take all steps to ensure these images are used solely for the purposes for which they are intended. If you become aware that these images are being used inappropriately, please inform us immediately.

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19 North Park Road
Harrogate
HG1 5PD
01423 752828
[email protected]

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