Senior Membership

Section 1 - Personal Details

Name

Gender

Date of Birth

Address including Post Code

Mobile Telephone Number

Any alternative Telephone Number

Section 2 – Emergency Contact Details

In the event of an incident or emergency, please provide details of someone who should be contacted by the Club. Please make this person aware that their details have been provided as a contact for the Club:

Emergency Contact Name

Emergency Mobile Telephone Number

Any alternative Emergency Telephone Number

Section 3 – Information about any Impairment

We will use this information for statistical purposes as well as to establish if there are any additional needs / support / adjustments that you may require, please discuss this with us.

The Equality Act 2010 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 have any physical or mental health conditions or illnesses that have lasted or are expected to last 12 months or more?

Does this disability or illness affect you in any of the following areas? Vision impairment, Hearing impairment, Mobility impairment, Dexterity impairment, Learning impairment, Memory impairment, Mental Health impairment, Stamina, Breathing or Fatigue impairment, Developmental impairment? If so, please provide us with any additional information so we can ensure you are fully supported

Section 4 – Medical Information

Name of Doctor / Surgery

Doctor / Surgery telephone number

Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, current medication, injuries etc.)

I consent to medical and disability information being shared in accordance with the Data Privacy Statement

Section 5 – Data Privacy

The Club will use the information provided on this Membership Form (together with other information it obtains about you) to administer your cricketing activity at the Club and in any activities in which you participate through the Club .

In some cases this may require the Club to disclose the information to County Boards, Leagues and to the England and Wales Cricket Board. In the event of a medical issue or child protection issue arising, the Club may disclose certain information to doctors or other medical specialists and/or to police, children’s social care, the Courts and/or probation officers and, potentially to legal and other advisers involved in an investigation.

Full details are provided in the club Privacy Notice, which is available on the club website, at the club house or on request. As the person completing this form, you must ensure that each person whose information you include in this form knows what will happen to their information and how it may be disclosed.

Section 6 – Annual Membership Fees (please add amount)

Ordinary Members £80

Ordinary Members who are unemployed or over 18 and in full time education or apprenticeships - £60

Ladies who only want to play in the Softball League - £45

Social Members £20

N.B Social Members are not entitled to selection for any team but may be selected for any team at the discretion of the Selection Committee.

Add Membership Amount due here (please just type number without £)

Please tick here for an Honorary Life Member

Please send the appropriate Membership Fee by Direct Bank Transfer into the following account:

Account Number: 80432512

Sort Code: 20-19-95

Name: Galleywood Cricket Club

Please quote reference with your surname in format: Mship-surname

Section 7 - Consents

I consent to the club photographing or videoing/streaming my involvement in cricket in line with the Club Privacy Notice

By returning this completed form, I confirm that I have read and understood the permission statements and consents on this membership form and the Privacy Notice.

I confirm I have read, or been made aware of the Club and ECB policies and agree to abide by the Club Code of Conduct.

I confirm that to the best of my knowledge all information provided in this form is accurate and I will inform the club of any changes to this information in a timely manner.

Signature (Print Name)

Signature Date