Application Form
(Paper Copies available on club nights)
First Name:
Surname:
D.O.B:
E-Mail: (REQUIRED)
Please provide a regularly used e-mail address
Home Address:
Postcode:
Emergency Home Phone No:
Emergency Mobile No:
School:
Please give any information regarding medical conditions, food allergies or special dietary requirements here:
If you consider that your child has a disability/Impairment please indicate which type(s)?
Physical [ ] Learning [ ] Visual [ ] Hearing [ ] Speech/Language [ ]
I parent/carer have read through, understood and will abide by the Code of Conduct for Parents, Carers and Specctators [ ]
I have discussed the Code of Conduct for Children, with my child as named above and he/she understands and agrees to abide by it at all times. [ ]
I understand that if either Code of Conduct is broken at any time, my child’s place on the scheme may be removed without refund [ ]
I hereby give permission for medical assistance to be appropriately given to my child. I understand that whilst staff in charge of the group will take reasonable care of the children, they cannot be held responsible for any loss, damage, or injury suffered to my child arising during or after the course, unless directly caused by reasonable negligence of the staff.
I hereby agree that my child’s photo may be used for Publicity purposes (no name) (Yes / No)
Please delete as appropriate
If member is under 18 please complete the following:
Parent’s/Guardian’s signature ……………………………………………………..………
Parent’s/Guardian’s name …………………………………………………………..………
(Please Print)
Date .…………………………………………….......……………………………….……….
Membership Fee - £30 per term
Please make cheques payable to 3 Counties Lacrosse and forward together with your application form to The Treasurer, 3 Counties Lacrosse,
For further details e-mail info@3-counties-lacrosse.co.uk
Telephone: 07875 283 542
P O Box 53, Malvern, Worcs, WR14 2ZB