Views External

Identity

Forename

Surname

DateOfBirth

Demographic

Gender

Ethnicity

Religion

Address

Address 1

Address 2

Town

County

Post Code

Contact

Telephone

Mobile

Email

Doctor Name and Address

Doctor's Phone

Parent or Guardian Facebook:

Parent or Guardian Instagram:

Other Information

Details of any allergies, illnesses, disability, dietary restrictions or medication, etc (this will not affect your childs place)

What Year Group Are You In?

Referral Criteria

Please provide contact details of a parent / carer that we can contact if needed:

Safeguarding

Our child is in full good health and we consider them capable of taking part in football activities.

We have completed the Medical Details part of this form and consent, In the event of any illnesses/accident. Any necessary treatment can be administered to my child.

I also understand that while coaches will take every reasonable precaution to ensure that accidents do not happen, they cannot be held responsible for any loss, damage or injury suffered by our/my child

The information provided on this form will be transferred and kept for a period of twelve months on a database. After twelve months you will be sent a renewal form, or you contact us at anytime requesting to be removed from the database.

We agree that photographs and or video footage may occasionally be taken during training or matches and used for promotion and training purposes. I give consent for my child to feature in said photos or footage.

I hereby grant only Phoenix United FC (Phoenix Utd CIC) and authorised partners and agents of the programme, the right to use the images created from any approved photographic or video sessions.

Soccer Gems (3-5 years old)