Logo

WESTMINSTER SCHOOLS FA - PLAYER REGISTRATION FORM

The information requested be for the safety and wellbeing of the participants, please answer all questions truthfully and accurately as possible. Please inform Westminster Schools FA, in writing, if any changes occur to the information given.

PARTICIPANT DETAILS

Please Complete in BLOCK CAPITAL letters

Accommodation Status: *
Telephone number(s): *
Gender: *
Are you in: *

ETHNICITY

What is your ethnic group? Choose one from the following sections and tick the appropriate box. Categories provided by the Home Office & CRE

White:

Chinese:
Mixed:


Asian or British Asian:


Black or Black British:


(If not English)

REFERRAL INFORMATION

MEDICAL INFORMATION

We do not exclude because of medical needs. However it is essential that we have full details in order to offer the best standards of care

Do you have?
Are you currently being prescribed any medication? *

(If YES please state details. i.e. times to be taken, dose etc.)
Have you been in contact with or had any contagious or infectious disease in the last four weeks? *

(If YES then please give details)
Have you had a tetanus injection in the last 5 years? *

(If YES then please give details)

GP CONTACT DETAILS

DISABILITY

Do you consider yourself to have a disability? *

Do you require one to one support / assistance? *

(eg: Visual Impairment, Physical Disability, Multiple Disability, Hearing Impairment, Learning Disability or Other)

EMERGENCY DETAILS

In case of an emergency during the activity, please could you write down two contact names, addresses and telephone numbers?

Contact 1 * Contact 2 *
Name: *
Address: *
Telephone – Home: *
Telephone – Work: *
Telephone – Mobile: *

ACTIVITY INFORMATION

Please tick & initial next to the activities you agree for the person named above to participate in:

   

YOUR (IF 18 YEARS OR OLDER) / PARENT / CARER CONSENT & DECLARATION

I consent to the person named above participating in Westminster Schools FA activities, as described above. I also consent to the person named above being escorted by Westminster Schools FA to and from activities on the programme, by vehicle both public & private and as a pedestrian. I recognise that the accompanying staff will be responsible for their supervision and care as far as can be reasonably expected. I understand that they will not be constantly supervised. I acknowledge the need for mature and responsible behaviour of the person named above and I believe that this can be expected of them.

I agree to inform Westminster Schools FA in writing, as soon as possible of any changes to medical circumstances of the person named above either prior to or during the programme. I agree that in an emergency Westminster Schools FA or its representatives may authorise medical treatment for the person named above including anaesthetic, if it is not practicable to consult me first. I will indemnify Westminster Schools FA and its representatives, agents & employees in relation to acting in ‘’loco-parentis’’ in the case of medical emergencies only.

I agree to indemnify Westminster Schools FA, its representatives, agents & employees, from all liabilities in relation to loss or damage suffered or caused by the person named above or which result from the person named above failing to follow any reasonable instructions given to them other than loss or damage resulting from the negligence of Westminster Schools FA or their representatives.

I understand that photographs, audio and visual recordings of the participant engaged in Westminster Schools FA activities may be used for promotional or other materials, such as websites, local and national media I hereby give irrevocable permission for this. I agree that I and the participant shall have no right to the recordings and all recordings belong to Westminster Schools FA.

I understand that the information given may be kept on a computer database, which will only be accessed by Westminster Schools FA. I confirm that I agree with the above declaration and the information on this form is complete and accurate to the best of my knowledge.

(Please note that Westminster Schools FA, its agents, employees and representatives cannot be held responsible for the loss or damage to participant’s property and Westminster Schools FA reserves the right to refuse participation of any person if there are concerns raised by the response on this form, especially if it’s due to misbehaviour of the young person.)