Belhus Cricket Club

 Membership Application Form 2010

Headquarters and Main Ground: The Village Green, North Stifford, Grays, Essex RM16 5UG. Telephone 01375 385505.

Welcome to Belhus Cricket Club.  To ensure that we have your correct contact details, please complete  and return this form to Jim Robertson, The Ferns, 124 Mollands Lane, South Ockendon, Essex, RM15 6DL.  If you are under 16 years of age please ask a parent or guardian to sign the form.

                                                                                          Personal

Name

Address

Postcode

Telephone:                               Home                                     Work                                                      Mobile

Email address(es)

If in Full-time Education, Name of School or College

School Year                                                If Employed, Occupation

Date of Birth                                             Gender (please tick one box)   Male  ð           Female  ð

Sports Equity Monitoring – Introduction

Whilst it is not compulsory that this section is completed, the following explains why it is important.  Sport can, and does, play a major role in promoting the inclusion of all groups in society.  However, inequalities have traditionally existed within sport, particularly in relation to gender, race and disability.  Sport England is committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them.  By monitoring the profile of young people in sports clubs, national governing bodies of sport and Sport England can identify any issues relating to under-representation of different groups and can together develop strategies to ensure that all young people have the opportunity in the future to develop and progress in sport.

Sports Equity Monitoring – Ethnicity

In order to help the club monitor its membership, would you please tick one of the first boxes from one of the rows. Choose one row then ensure one further box on the same row is completed to help identify your ethnic group/origin.

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’.

If yes, what is the nature of your disability?  (please tick appropriate boxes)

Sporting Information

If yes, where have you played?  (please tick appropriate boxes)

Detail below any important medical information of which our coaches/managers/senior team captains should be aware

(e.g. epilepsy, diabetes, asthma).

..........................................................................................

Emergency Contact Details

(Essential for members under the age of 18, optional for all other members)

        Names           (1) Parent/Guardian                          (2) Carer

        (1) Telephone: Home                              Work                                        Mobile

        (2) Telephone: Home                              Work                                        Mobile

 
       Membership Fees 2009

Declaration

I agree, on becoming a member of Belhus Cricket Club (‘the club’) or by signing as a parent or carer of an applicant under the age of sixteen years, to accept the terms and conditions of the club as laid down in the club’s Constitution, its codes of conduct including the England and Wales Cricket Board (ECB) “Safe Hands” child protection policy and any notices that may be displayed within club premises from time to time.  I understand that it is my responsibility to arrange personal accident insurance if required and agree that the club and/or its agents cannot be held liable for any loss or damage howsoever caused.  I agree and accept that the contact details on this form may be transmitted, either manually or electronically, between club officers for normal club administration purposes and I give consent for these details to be given to the organisations to which the club has affiliated, where reasonable and appropriate.  Such examples may include, though may not be limited to, player and coach development/education and nomination for any appropriate representative cricket squads.  If I undertake coaching activities at the club, I agree to be bound by the ECB coaches’ code of conduct and that I am required to undertake a Criminal Records Bureau (CRB) check.  If I am an adult signing on behalf of a member under the age of sixteen years of age, I confirm that I am the parent or recognised carer of the applicant named on page one of this form and that I give my consent for the applicant to participate in the activities of the club, that I will be kept informed of these activities and that I will advise the club secretary of any subsequent changes to the medical or emergency contact details provided herein.  I give consent to the above named being included in any normal press releases and/or video and/or television and/or photography and accept that it is my responsibility to notify the club secretary in writing should I wish to withdraw this consent.  I understand that in the event of any injury or illness to the above named, all reasonable steps will be made to contact me and to deal with that injury or illness appropriately.

Name (print)                                        Signature                                      Date