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Kensington Impact FC (Progressay Impact) - Players Registration and Parent Consent Form

Where?: Emslie Horniman (Teletubby Park) Kensal Rd, London W10 5EG When?: Tuesdays | age 8-11: 6pm-7pm | age 12-16: 7pm-8pm
Where?: Pitch 1, Westway Sports Centre, 1 Crowthorne Rd, London W10 6RP When?: Saturdays | age 5-7yrs: 1pm-2pm | age 8-11yrs: 2pm-3pm
Dear Parent / Guardian & Player.

Welcome to Junior and Youth Football at Kensington Impact Football Club!

For some, this will be your first experience of our club, and we warmly welcome you.

Please ensure you complete and read all sections, anything added to this form will be held in confidence.

The club and our coaches need to know these details in order to meet the specific needs of your child.

Kind regards,

Moktar Alqaderi (PGCE, QTS)

CEO

Kensington Impact

Progressay Impact

Progressay Impact Membership
Is your child already a Progressay Impact Member?

YesNo
If known, what is your Progressay Impact Membership number (USERID)? (Leave if unknown)

Player details
Team (please select)*
Players Name*

First NameLast Name
Gender

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Which borough do you live in?*

Kensington and ChelseaHammersmith and FulhamWestminsterOther
Which ward do you live in?
If "other", please specify:
Date of Birth*

MonthDayYear
Date
Age*
School Attending
Previous Club Registered
Select your child's ethnicity*
If "other", please provide details:

Parent / Guardian Information
Full Name of Parent/Guardian*
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Relationship to the child*
father, mother, guardian etc.
Select your ethnicity
If "other", please provide details:
Address:

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Alternative phone Number

Area CodePhone Number

Special Education Needs
Does your child have Special Educational Needs?

YesNo
Does your child have of the following:

ADHDAutismOther
If "Other", please provide details:

Emergency Contacts
Additional Emergency Contact Details (if the parent / Guardian cannot be reached)*

First NameLast Name
Phone Number*

Area CodePhone Number

Players Code of Conduct
I have read, understood, and hereby agree to abide by the above players code of conduct. I will also ensure my child will read and abide by the code.*

Yes

Parents Code of Conduct
I have read, understood, and hereby agree to abide by the above Parents code of conduct.*

Yes

Consent for photographs and videos to be used in by Progressay Impact CIC
Consent extends for these photographs and or videos, in which you/your child(ren) may feature to publicise the different services, activities and consultation offered and carried out by Progressay Impact CIC and our Partners.

Consent also extends to sharing photographs and or videos with our Partners, which includes but is not limited to, organsiations that provide funding such as Kensington and Chelsea Council, Kensington and Chelsea Social Council, Young K and C and The WestWay Trust.

These images/videos may be used on a variety of channels including, but not limited to:
- Impact Reports for monitoring purposes
- www.progressayimpact.co.uk
- www.progressay.com
- https://www.tiktok.com/@progressayimpact
- https://www.instagram.com/progressayimpact/
- Twitter
You consent to being photographed/ filmed at Progressay Impact's Sessions typically held at the following places:
- Unit 12, Latimer Road, W10 6RQ
- Westway Sports Centre
- St Charles Football Pitch
- Other
This may include Images/ Videos you yourself share that demonstrate Impact.

Notes:
- Once these images and videos are in the public domain Progressay Impact CIC and or our Partners, will have no control over them. This will not stop you from asking Progressay Impact CIC and or our Partners to stop storing, altering or erasing them.
- Please also note that unfortuantely we are unable to exclude individuals from group photographs/videos due to technical demands this requires. If you are unable to consent, this may mean you are unable to attend. Please contact us should you have any issues at: info@progressay.com
I agree to photographs/videos of my son/daughter being taken by Progressay Impact for promotional purposes.*

YesNo

Pricing
See Subscription Package: - (Please skip this part if you have discussed this with our team)
prevnext( X )
PLAY - Football 4 All£9.00
Play for one hour a week (Saturdays)----£9 per month If UC, then 85% discount will reduce this to only £1.50 per month

Quantity

TRAIN - Pro Impact£29.00
Play for two hours a week + Tuesdays and Saturdays (1 hour each) ---- £29 per month If UC, then 85% discount will reduce this to only £4.50 per month

Quantity

COMPETE - Kensington Impact FC£59.00
Play for two hours a week + Tuesdays and Saturdays (1 hour each) + Compete in a local league ---- £59 per month If UC, then 85% discount will reduce this to only £9 per month

Quantity

Total £0.00

Sign & Submit
Player Registration is not complete until this form has been Signed and Submitted. I hearby confirm all information provided in this Player Registration & Consent form to be accurate to the best of my knowledge.

Please note payment must be made at the start of the month in advance and that payment is not based on attendance. This means that you will be charged whether you attend or not, as payment is required to reserve your child's space.
Name*

First NameLast Name
Signature*

Clear
Should be Empty:

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Kensington Impact FC (Progressay Impact) - Players Registration and Parent Consent Form