Registration for - Ability / Disability Football

Should you have any issues using this form please contact Mike on mike@brackleytownfc.co.uk. Please do not contact/email anyone else as this will be your quickest way to get an answer to your problem

Please provide the details of two people who we can contact if required, one of which must be a parent/guardian

Primary Contact Details Parent/Guardian

PrimaryContactName(*)

Your Name

Primary Contact Relationship(*)

Please specify relationship to child

Primary Contact Date of birth(*)

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Primary Contact Email where all communication will be sent(*)

Please specify your email address.

Primary Contact Landline Number(*)

Please specify land line phone number, no spaces

Primary Contact Mobile Number(*)

Please specify mobile phone number, no spaces

Primary Contact House Number/Name(*)

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Primary Contact City/Town(*)

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Primary Contact Road/Street(*)

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Primary Contact County(*)

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Primary Contact Post Code(*)

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Second Contact Details

Second Contact Name(*)

Please specify your name

Second Contact Email(*)

Please specify email address.

Second Contact Mobile Number(*)

Please specify mobile phone number, no spaces

Second Contact Landline Number(*)

Please specify land line phone number, no spaces

Second Contact Relationship(*)

Please specify your relationship to child

Items marked with an * are required.

Players Personal Details

Players Full Name(*)

Please input players name

Date of birth(*)

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Medical Details

Childs Doctors Name(*)

Please specify your doctors name

Childs Doctors Street Number/Name(*)

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Childs Doctors Road/Street Name(*)

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Childs Doctors City/Town Name(*)

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Childs Doctors County Name(*)

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Childs Doctors Post Code(*)

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Childs Doctors Phone Number(*)

Please specify doctors land line number, no spaces

______________________________________________________________________________________________________________________________________________

Please state medication the player is taking for example inhalers and epi pens. If your child/player has an inhaler and epi- pen they must bring it to each training and game. Should any details for your child change please advise us. Please remember that it is your responsibility to complete the declaration truthfully.

Please be advised BTFC staff are not allowed to administer medication.

Is the player currently taking medication?(*)

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(*)

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Has the player any allergies ?(*)

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(*)

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Does the player have a care plan?(*)

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______________________________________________________________________________________________________________________________________________

Is child/player suffering from any medical conditions that we should know about such as physical disabilities, sight, hearing, autism, ADHD, social anxiety, finds change difficult etc. Any information you give us helps the coaches support your child/player so full medical information is essential. Should any details for your child change please advise us. Please remember that it is your responsibility to complete the declaration truthfully.

Please be advised BTFC staff are not allowed to administer medication.

Is the player suffering ADHD diagnosed or being assessed?(*)

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(*)

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Is the player suffering from any sight issues?(*)

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(*)

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Is the player suffering from any hearing issues?(*)

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(*)

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Is the player suffering from any Autism issues - diagnosed or being assessed?(*)

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(*)

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Is the player suffering from any social anxiety?(*)

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(*)

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Has the player any Physical Disabilities?(*)

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Has the player any Physical Disabilities(*)

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Has the player ever suffered from any injury which you feel we should know about?(*)

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(*)

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Is there anything else you think we should know about player?(*)

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(*)

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Items marked with an * are required.

Disclosures

• Parent/Guardian - I agree to abide by the Rules and Codes of Conduct of Brackley Town Football Club, the league, and the FA

Parent/Guardian - I agree to abide by the Rules and Codes of Conduct of Brackley Town Football Club, the league, and the FA(*)

yes

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I give my permission for any appropriate medical treatment to be carried out

Parent/Guardian - I give my permission for any appropriate medical treatment to be carried out(*)

yes

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I agree that photos or video may be taken whilst the above-named player is taking part in any club or league organised activity - Photos will be used on the clubs website & social media.

Parent/Guardian - I agee that photos or video may be taken whilst the above named player is taking part in any club or league organised activity(*)

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• Player - I agree to abide by the Rules and Codes of Conduct of Brackley Town Football Club, the league, and the FA

Player - I agree to abide by the Rules and Codes of Conduct of Brackley Town Football Club, the league, and the FA(*)

yes

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Items marked with an * are required.

Finally, to complete registration you must read and agree the following

Our Safegurading & Data Privacy Policies can be read HERE tick box below to confirm acceptance

I have read and accept Our Safeguarding and Data Protection & Privacy Policies(*)

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You will be added to our mailing list

BTFC Newsletters keep you updated on what’s new at Brackley Town FC including:

Latest team news - Football in the community news - Saints Community project news - And more

These Newsletters will normally arrive in your inbox at most once a month unless we have some urgent news that we think you might be interested in. There is an unsubscribe link on all newsletters, so you can unsubscribe at any time

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Items marked with an * are required.

Once form is completed click on 'Confirm registration'

You will receive an automated email confirming your registration

Thank you for your support BTFC Player Development Centre

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