This form has to be completed annually and will be taken to each event by a leader.
Name of Player _________________________________
Age on 1st Sept _____ Date of Birth ________________
Address __________________________________________________________________
Post Code __________________
Tel No _____________________
E mail address _________________________________________________________
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 _______________
Please print name __________________
Address (if different from player) _____________________________________________