LOASS FC Contact and Consent Form
2019-20
Player details
Age group
*
Please Select
U7
U8
U9
U10
U11
U12
U13
U14
U15
U16
U18
Gender
*
Please Select
Boys
Girls
Team name
*
Please Select
Spitfires
Hurricanes
Tornadoes
Enter Spitfire if one team
Player's first name
*
Player's surname
*
Player's date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Main contact email
*
Main home address
*
Street Address
Street Address Line 2
City
Postal / Zip Code
Main contact tel Number
*
Standing order reference
Parents details
1st Contact name
*
1st Contact Mobile Number
*
1st Contact Email
*
2nd Contact name
*
2nd Contact Mobile Number
*
2nd Contact Email
*
1st Contact home address same as main
*
Yes
No
1st Contact Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2nd Contact home address same as main
Yes
No
2nd Contact Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School details
School Name
*
Medical information
Please state if you have any medical condition that you think we should be aware of:
*
None
Please state if there are any special requirements you have regarding diet:
*
None
Please state of any other considerations with regard to your child.
*
None
Consent declaration
Video/Photo Release Authorisation
I give permission to LOASS FC and/or parties designated by LOASS FC to photograph the person named above and use such photographs in all forms of media, for any and all promotional purposes including advertising, display, audio visual, exhibition or editorial use. I further consent to the use of the name of the person named above in connection with the photographs if needed by LOASS FC.
*
Yes
No
3rd party information
The information you provide will be held in strict confidence by LOASS FC. I consent to my details being forwarded upon request to professional football clubs and the Football Association which will only include the player’s contact and ethnicity details.
Yes
No
Consent Declaration
I give permission for my child to take part in this activity that may also involve trips organised by LOASS FC and I am willing for LOASS FC volunteers to act on my behalf for the welfare of my child in the event of an emergency. We agree to stand by the LOASS FC rules and adhere to its Code of Conduct, including ensuring all fees are paid in full, on time and understand that failure to do so will result in disciplinary action being taken which could result in your child being suspended from playing any organised football. I understand that I will not be offered a refund for registration or monthly fees should my child(ren) decide to leave LOASS FC throughout the season and will be liable to pay any outstanding amount. Please tick the consent checkbox below and submit the form by clicking the submit button
*
I agree to the consent declaration
Gift aid
I confirm that I pay an amount of UK income or capital gains tax annually that is no less than my annual donation and want the Club to claim Gift Aid on my donations
Gift aid
Signature
Submit
Should be Empty: