Player Name * First Name Last Name Parent/Guardian Name * First Name Last Name Parent/Guardian Email * Phone Number * (###) ### #### Address * Player DOB * MM DD YYYY Current Age Group * Preferred Session * Please select what kind of session you would like to attend. 1-2-1 Session Small Group Session Preferred Day/s * Please select what days you are available to attend our sessions. You can select more than one. Monday Tuesday Friday Preferred Coach * Please select which coach you would prefer. Laurie Ethan Dan Harrison Position Current Team/s Emergency Contact 1 * Please provide NAME/PHONE/RELATIONSHIP TO PLAYER Emergency Contact 2 * Please provide NAME/PHONE/RELATIONSHIP TO PLAYER Ethnicity White British Black British White Other Black Other Asian Mixed race Prefer not to say Does the player have any medical conditions/allergies? * Yes No If "yes" above, please give details in the box below Media Consent * This is to certify that I have no objections to Worksop Town Academy or associated company using any photographic or video images of my child whilst attending a Worksop Town Academy event. Any images will only be used to promote the work of Worksop Town Academy to partners and funders along with local, national and social media outlets. I agree I do not agree Parent/Guardian Consent * We are committed through trained and competent staff to providing a safe learning environment, however football is a contact sport and injuries may occur through no negligence of our staff. We feel it is our responsibility to ensure the safety of the attendee by making sure they come well equipped for the activity i.e. correct footwear, appropriate clothing, food/drinks if appropriate, medication (if applicable). I have read and understood this form, completed all the details requested to the best of my knowledge and will comply with the information set out. I acknowledge and accept that Worksop Town Academy or respective servants shall not have any liability in respect with any loss or damage to property and give permission for my child to receive emergency medical treatment in my absence if deemed necessary. I agree I do not agree Thank you!
