This form has to be completed annually and will be taken to each event by a leader.

Name of Player ________________________ Age on 15/9/01 _______________

Date of Birth ___________________

Address _______________________________________________________________________________________

Post Code __________________________

Tel No _____________________________

E mail add __________________________

Other contact number(s) to be used in any emergency ______________________________________

Nat Health No _______________________________________

School attended _____________________________________

Family Doctor ___________________________________ Tel No _________________________

Address __________________________________________________

Post Code _____________________________

Does the player suffer from any recurrent illness e.g. glandular fever. Asthma. Eczema.

YES/NO. If yes please provide details-

Does the player require medication?

YES/NO If yes please provide details.

When did the player last receive inoculation against tetanus? ___________________

Has the player been in contact with any infectious illness over the last few weeks?

YES/NO if yes please provide details.

Please provide details of any other medical condition that the leaders should be aware of.

In the event of illness/injury requiring emergency treatment. we authorise a registered leader/helper to sign on my behalf, any written form of consent required by the medical staff. If the delay required to obtain my own signature is considered inadvisable or unnecessary by the medical staff.

We give our permission for the player named to participate in the Churches together football league and also any events organised by the club/league

We give our permission for the player to travel in vehicles used as part of the transport rota. Or arranged separately by the leaders for special events./or in another vehicle if exceptional circumstances dictate, At the discretion of the leaders. We have read and retained the Club information sheet. (you may also wish to retain a copy of this form)

Signed Player ________________________________________

Signed Parent/Guardian _______________________ Date / /200

Please print name _____________________________

Address (if different from player)___________________________