Purton Cricket Club - 2022 Adult Membership Form

Purton Cricket Club - 2022 Adult Membership Form

We are very pleased to welcome you to Purton Cricket Club. This adult membership form should be completed by all persons over the age of 16 years old. Once completed please email membership.purtoncc@gmail.com to confirm completion of form and payment method. We will use the contact details provided for all club communications.
Section 1: Personal Details
Prefix First Name Last Name
Birth Date

Month Day Year
Gender *
Section 2: Personal Contact Details
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number

Area Code Phone Number
Home Number

Area Code Phone Number
Section 3: Emergency Contact Details
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Phone Number
Email
example@example.com
Section 4: Nationality & Residence Details

Complete this section if you DO NOT hold a valid UK passport to comply with ECB directive.
Nationality
Resident In The UK Since

Month Day Year
Date
Date last entered the UK

Month Day Year
Date
Section 5: Membership
Membership Type

Section 6: Disability

The disability discrimination act 1985 defines a disabled person as, anyone with a physical or mental impairment, which has a substantial 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?
If yes, please detail below.
Section 7: Medical, allergy or injury information

Please detail below any important information that our coaches need to know.
Medical Consent - I give permission that in the event of a medical emergency, the club may act in Loco Parentis, if the need arises for emergency administration of first aid or other medical treatments. I also understand that in the occurrence of such an event, Purton CC will make reasonable steps to contact the emergency contact above.
I confirm to the best of my knowledge, I do not suffer from any medical condition that is not listed above.
Section 8: Data Protection
The club will use the information provided on this membership form (together with other information it obtains about the player) to adminster his/her cricketing activity at the club and in any activities in which he/she participates through the club and to care for and supervise activites in which he/she are involved.

In some cases, this may require the club to disclose the information to county boards, leagues and to the England and Wales Cricket Board (ECB). 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, social care, the courts and/or probation officers and, potentially to legal and other advisers involved in the investigation.

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.

The clubs general data protection regulations (GDPR) privacy statement, can be found on the club website.
Section 9: General Consent
By signing this completed Membership Form, I agree to take part in the activities of Purton Cricket Club. I understand that I will be kept in informed of the activities of Purton Cricket Club.

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

I confirm that I have read the clubs Code of Conduct for Club Members and guests and agree to abide to it.

I agree that I will purchase and wear the clubs current match day kit, as sold in the club web shop. I also understand that failure to do so, may effect selection for club fixtures.
Signature

Clear
Date

Month Day Year
Date
Section 10: Further Information
Do you have a cricket coaching qualification
If yes, please provide details below.
Purton Cricket Club is a members run club and survives on volunteers. Please highlight below if you are willing to volunteer to support the club and a member of the committee will be in contact.
Section 11: Welfare
Any welfare issues much be raised via emailing welfare.purtoncc@gmail.com and chair.purtoncc@gmail.com
Section 12: Payment Information
Payment Type:
Purton Cricket Club Account:

Bank Name: Lloyds Bank, 5 High Street, Swindon, Wiltshire, SN1 3EN

Sort Code: 30-98-41

Account Number: 00029638

Reference: Please add member name as payment reference.
Should be Empty:

Purton Cricket Club - 2022 Adult Membership Form

Section 1: Personal Details

Section 2: Personal Contact Details

Section 3: Emergency Contact Details

Section 4: Nationality & Residence Details

Section 5: Membership

Section 6: Disability

Section 7: Medical, allergy or injury information

Section 8: Data Protection

Section 9: General Consent

Section 10: Further Information

Section 11: Welfare

Section 12: Payment Information