PENRITH PUMAS JUNIOR RUGBY LEAGUE FOOTBALL CLUB

 membership Form 2011/2012 Season – UNDER 12 AND OVER

MEMBERSHIP SUBSCRIPTIONS	
JUNIOR PLAYER	£35	
NON PLAYING ADULT	£10*	
FAMILY (up to 2 non playing adults and 2 playing children)	£60*	
*As an adult member or adult member  within a family membership, you will have a vote and be  entitled to attend the AGM.  You will be eligible to receive discounted match tickets should the club be in receipt of any from the RFL and will be entitled to discounts on any trips organised by the club.
Please indicate the subscription you require. Cheques should be made payable to “Penrith Pumas”

Junior			Adult   		         Family   

MEMBERS CONTACT DETAILS	
NAME	ADDRESS	TELEPHONE/EMAIL	DOB (if under 18)	
		Landline:

Mob:

Parents Mob (U18s)

Contact email

		Landline:

Mob:

Parents Mob (U18s)

Contact email

		Landline:

Mob:

Parents Mob (U18s)

Contact email

	

		Landline:

Mob:

Parents Mob (U18s)

Contact Email

Please note:

Most communication will be via email. Make sure that you enter an email address that is regularly monitored. If you enter your son/daughters email address, then we take this as your agreement that correspondence can be sent directly to them as well as yourselves.

TO BE COMPLETED BY THE PARENT OR GUARDIAN OF JUNIOR PLAYER:  
medical information
Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g epilepsy, asthma, diabetes, etc.)

TO BE COMPLETED BY PARENT/GUARDIAN

Please insert the information below to indicate the person(s) who should be contacted in case of an incident/accident:

Contact name (e.g parent/guardian): 	

Emergency contact number:	

I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.

Name of parent/guardian:	

Signature of parent/guardian: 	

Date: 	

Please read the notes below and sign to accept the terms and conditions of membership of Penrith Pumas.

I would like the above named to join Penrith Pumas Junior Rugby League Club. I understand that Penrith Pumas Junior Rugby League Club, its servants, agents or employees are not under any liability whatsoever for loss of property, accidents or injuries, however caused, during the course of preparations, training, touring, playing or travelling either at Penrith Pumas or elsewhere. I understand that I remain responsible for my own child/children and that all people involved in the running of Penrith Pumas Junior Rugby League Club are volunteers and not employees of the Club.

I accept that Penrith Pumas Junior Rugby League Club will as far as is reasonably practicable, keep any personal information confidential within the Club and I accept that by signing this form, I agree to share all information provided with Penrith Pumas Junior Rugby League Club and it’s voluntary officials.

I also agree that my family, my child and I will comply at all times with the code of conduct, constitution, rules and policies of Penrith Pumas Junior Rugby League Club and I understand that any breach of the aforementioned policies and rules, by persons belonging to or connected with my family, could lead ultimately to expulsion from the club.

I understand that the club may take photographs, or make video/DVD recordings of the children at Penrith Pumas Junior Rugby League Club either individually, in groups or as teams, during the season or on trips. The club may use these photographs for training purposes, in Club literature, on the club website or may on occasion,  allow images to be used by appropriate external bodies to promote the activities of the club, e.g. local press. No contact details will be given, but it may be necessary to add the name(s) of the child(children) where it is necessary in the context of the item

In order to comply with the Data Protection Act 1998 and the RFLs policies on Safeguarding , we require your permission to use any photographs or recordings we make of your child/children for the above purposes. Please tick the box below if you DO NOT want us to use recordings or photographs as described above. If you do tick this box, please note that it is impossible for the coaches, organisers and managers of the club to challenge every photographer at fixtures or events. If you tick this box YOU must be prepared to challenge those you see with cameras etc.

I DO NOT WANT IMAGES/RECORDINGS OF MY CHILD TO BE USED AS DESCRIBED ABOVE

FULL NAME..................................................................................  RELATIONSHIP TO CHILD........................................

SIGNATURE.................................................................................. DATE........................................................................