DORKING CC - COLTS APPLICATION FORM

PLAYER NAME

PLAYER DATE OF BIRTH

HOME ADDRESS

(Incl postcode)

EMERGENCY CONTACT NAME

RELATIONSHIP

HOME TELEPHONE

MOBILE TELEPHONE

EMAIL ADDRESS

2^ND EMERGENCY CONTACT NAME

RELATIONSHIP

HOME TELEPHONE

MOBILE TELEPHONE

EMAIL ADDRESS

DOCTORS NAME

TELEPHONE NUMBER

Please state if the player has any conditions or allergies

Conditions include diabetes, epilepsy, asthma etc

Any known allergy to medication should be clearly stated

Any medication commonly taken should be stated

Please state (and specify) if you have a disability

Previous Playing Experience (if any)

By returning this completed form, I agree to my son/daughter/child in my care taking part

in the activities of the club.

I understand that I will be kept informed of these activities – for example timing and

transport details.

I understand that in the event of any injury or illness all reasonable steps will be taken to

contact me, and I give permission for the club to administer any appropriate or necessary

medical attention.

I consent to the club maintaining records and information relating to my child on

confidential spreadsheets and databases, for the purpose of club administration. 

I understand that I have a right to see this information if I so desire, providing

I give appropriate notice to the club.

Cheque payable to “Dorking Cricket Club” attached (Y/N)

Parents Name :  _____________________________

Parent/Guardian’s signature _____________________________ Date______