Eastbourne Cricket Club

Membership Form

Eastbourne CRICKET CLUB

We are very pleased to welcome you to Eastbourne Cricket Club.  To ensure we have the correct contact details for you, please complete this membership form and return it to Paul Hacker, Chairman Eastbourne Cricket Club, Eastbourne Saffrons Sports Club, Compton Place Road, Eastbourne, East Sussex, BN21 1EA.

If you are under the age of 18 please also ask your parents/carer or guardian to sign the Membership Form before it is returned.  We will also use this information to ensure that you are kept informed about events and information from Eastbourne Cricket Club.  The information provided on this form may be submitted to Sussex County Cricket Club for development purposes.

Section 1 – Personal Details

Name:                   …………………………………………………………………

Address:               …………………………………………………………………

                              …………………………………………………………………

Town:                   …………………………………………………………………

Postcode:            …………………………………………………………………

Telephone

Number:               …………………………………………………………………

Mobile:                  …………………………………………………………………

E-mail:                  …………………………………………………………………

Date of Birth:       …………………………………………………………………

School/College:   …………………………………………………………………

Section 2 – Ethnicity

Whilst it is not compulsory that the following section is completed, the footnote at the end of this Membership Form explains why this section is important.

Please tick the appropriate boxes

A             White (  )                          British (  )                         Irish (  )

Any other white background (please specify): ………………………………………….

B             Mixed (  )                          White & Black Caribbean (  )

               White & Asian (  )           White & Black African (  )

Any other mixed background (please Specify): …………………………………………

C             Asian or Asian British (  )                                    Pakistani (  )

               Indian (  )                         Bangladesh (  )

Any other Asian background (please specify): ………………………………………….

D             Black or British Black (  )                                   Caribbean (  )

               African (  )

Any other Black background (please specify): ………………………………………….

E             Chinese or other ethnic group (  )                    Chinese (  )

Any other (please specify): …………………………………………………………………….

Section 3 – Disability

The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’.

Do you consider yourself to have a disability?   Yes (  )    No (  )

If yes, what is the nature of your disability?

Visual impairment (  )                   Hearing impairment (  )

Physical disability (  )                   Learning disability   (  )

Multiple disability  (  )

Other (please specify): …………………………………………………………………………..

Section 4 – Medical Information

Please detail below any important medical information that our coaches/colts section should be aware of (e.g. epilepsy, asthma, diabetes etc.)

Section 5 – Sporting information

Have you played Cricket before?                        Yes (  )    No (  )

If yes, where have you played Cricket: (please indicate below)

Primary school (  )                                                              Secondary school (  )

Local authority coaching session(s) (  )                         Club (  )

County (  )

Other (please specify): …………………………………………………………………………..

Section 6 – Emergency Contact Details

This section is to be completed by the parent/carer or guardian:

Please insert the information below to indicate the persons who should be contacted in the event of an incident/accident:

Emergency Contact Person 1:             Emergency Contact Person 2:

Name:                                                       Name:

Relationship                                            Relationship

to individual:                                           to individual:

Home Tel No:                                          Home Tel No:

Work Tel No:                                            Work Tel No:

Mobile Tel No:                                         Mobile Tel No:

By returning this completed Membership Form, I agree to my child in my care taking part in the activities of Eastbourne Cricket Club.  This includes my agreement to my child being transported to and from games being driven by a suitable driver vetted by Eastbourne Cricket Club.  I also give my permission for my child to take part in team photographs.

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

Name of parent/carer/guardian:

Signature of parent/carer/guardian:

Signature of Applicant:

Date:

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