Senior Membership Form Seniors Membership Form Seniors: Club Membership FormTo ensure that we have the correct contact details for you, all members are required to complete this form. This information will be used to keep you informed about Club events and to contact you or your next of kin in the event of an accident. Some of the information is required to comply with the England Hockey Equality Policy, which has been adopted by the club. All details will be kept in a secure database with access restricted to authorised Club officers only. Membership of the club is not complete, until both your membership form and payment are received. Any stage payments must be agreed in advance with your team captain or a Club Officer, and must be received in accordance with the agreed schedule for you to continue to be eligible to play. MEMBERSHIP FORMS FOR JUNIORS PLEASE CLICK HERE: http://www.cambridgecityhc.org/juniors/registration-formTitle*MrMrsMissMsFirst Name*Surname*D.O.B* Address* Address Line 1 Address Line 2 Town / City Province Postcode Home Telephone*Mobile TelephoneE-Mail Address* NewsletterCCHC send out a newsletter containing information about results, upcoming events and other useful information. We will assume that you would like to receive this unless stated otherwise below. Please do not subscribe me to the CCHC newsletter Membership TypeMembership Type*Senior Full Membership £180 per annum + £12 Match FeeConcessionary Membership - £100 (match fee £8)Junior Membership U18's - £130 (match fee £8)Veteran associate Membership / Non-playing Membership £30 (match fees as above)*If you have chosen concession membership please state why you qualifyUnemployedStudentRetiredPayment InformationPayment Method*More details regarding making payment will be shown once the form has been submitted.Bank Transfer (BACS)CashChequeMember InformationOccuptaion*Employer NameStudents: Which school/college/uni do you attend?Do you have umpiring / coaching qualifications?*YesNoGive details of your qualifications* Would you be interested in learning to coach / umpire?*(The club might be able to help / support you with this)YesNoHow might you be able to volunteer at the club?*(Example roles: Umpires, webmaster, secretary, fixtures manager, umpire liaison) Umpire Secretary Fixtures Manager Umpire Liaison Captain Coach (qualified or unqualified) Social Event Organisation Fund Raising Website Support I am unable to volunteer Other If 'Other', please specify:*Please list any of your skills you feel could help the club:(Examples: web design, accounting, printing, planning, marketing) Medical Information / Emergency ContactThe Club carries no Personal Accident insurance. In case of emergency and as part of the Club’s responsibility to its membership, ALL Club members are required to complete this medical information form as accurately as possible.Next of kin:*Relationship:*Next of kin Mobile Telephone:*As far as you are aware, are you allergic to any drugs?*YesNoIf yes, please specify:* Are you taking any long-term medication?*YesNoIf yes, please specify:* If you have any long-term illness or injuries, please list them here: Medical Declaration:*I consider myself (my son/daughter)* to be physically fit and capable of full participation and agree to notify the Club of any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission (for my son/daughter)* for the team managers/coaches appointed by CCHC to obtain emergency medical treatment on my behalf. I do / do not agree with the above Medical Declaration:I AgreeI Do Not AgreeParental Declaration:*Please make sure you read ‘Guidance for parents whose children are playing adult hockey’. It is a requirement of Club policy that parental consent is provided for participation, transportation, communication, changing and photography. The CCHC Code of Conduct and Child Protection Policy are available on the Club website (www.cambridgecityhc.org) and from the Club Secretary. TRANSPORTATION: I consent to my son/daughter travelling to venues for matches and training by transport provided by the Club which may include travelling in other players’ private cars. PHOTOGRAPHY: In some environments, particularly adult competition it is impossible to control photography by external parties, however, I am aware that there maybe times that photographs and/or footage maybe taken during matches and training sessions by approved agents and/or officers of CCHC. Such images shall only be used for publicity/training purposes in accordance with the CCHC Child Protection Policy and give consent for my son/ daughter to feature in such photos/ images. I hereby only grant approved agents the right to use the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes ie local newspapers, local magazines, other promotional articles (inc. flyers) and the Club’s website. COMMUNICATION: I consent to the relevant team captain contacting my son/daughter by telephone or email. Please include your details below so we are able to copy you into this correspondence. If you leave this blank we will not be able to copy you into this communication. CHANGING: I understand that young people playing in adult teams will share changing accommodation with adults. I do / do not agree with the above Parental Declaration:I AgreeI Do Not AgreeNot ApplicableParental Consent Contact DetailsFirst Name:*Surname:*Relationship:*E-Mail Address:* Mobile Number:*Ethnicity & DisabilityWhilst it is not compulsory for the following sections to be completed, the paragraph below explains why this personal information is considered to be important. Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have existed within sport particularly in relation to gender, race and disability. Sport England and England Hockey are committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of people in sports Clubs, national governing bodies of sport and Sport England can identify any issues relating to under representation of different groups and can develop strategies to ensure that all people have the opportunity in the future to develop and progress in sport. England Hockey requests this data from Clubs as part of the annual affiliation process and completing this data accurately enables the Club to give an accurate picture to England Hockey on our membership.Please choose the option which best describes your ethnicity:White BritishWhite IrishWhite OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianWhite - OtherAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - OtherBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - OtherChineseOther Ethnic GroupPlease indicate below any learning or physical disabilities: Deaf Visually Impaired Hearing Impaired Physical Disability Learning Disability Multiple Disability Other If 'Other', please specify:Please add any additional relevant information: The End!Thank you for taking the time to submit this form. Once you submit the form, your details will be stored in a secure database and you will be shown a confirmation page containing more information about making payments to CCHC.