Player Information & Parental Consent Form 2022/23
Player Information
Player Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Primary Address
*
Street Address
Street Address Line 2
City
County
Post Code
Number of years playing ice hockey
Parent Guardian Information
Primary ParentGuardian Name
*
First Name
Last Name
Relationship to Player
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Work Contact Number
Mobile Number
*
Secondary ParentGuardian
First Name
Last Name
Relation to Player
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Contact Number
Mobile Number
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Medical Information
Name of GP Surgery
*
Phone Number
*
Does the player have any allergies?
*
Yes
No
If yes please name allergies
Does the player have asthma?
*
Yes
No
Is the player diabetic?
*
Yes
No
Is the player epileptic?
*
Yes
No
Does the player have a social worker or any local authority intervention?
*
Yes
No
Does the player receive any emotional or wellbeing interventions?
*
Yes
No
Does the Player have a health problem that could interfere with himher participating in a full ice hockey programme?
*
Yes
No
Does the player have hearing problems?
*
Yes
No
Does the Player wear Glasses?
Yes
No
Has the player had any injuries needing medical help or had surgery in the past year?
*
Yes
No
Has the player had any illnesses in the past year lasting longer than 1 week?
*
Yes
No
Does the player wear a medic alert bracelet or necklace?
*
Yes
No
Is the Player on Regular Medication?
*
Yes
No
Has the player been hospitalised in the past year?
*
Yes
No
Please use this box to provide details of any disability that could interfere with himher participating in a full ice hockey programme
Depending on Age Group, your child may need help dressing\undressing, going to the toilet etc. Please note that is such help is necessary and you will not be able to provide it, your signature below will include consent to the activity organiser making the necessary arrangements. I\We give permission for my\our child, named above to be given first aid\medical attention, which may include attendance by medical staff or hospital treatment. I also acknowledge that MSA will not be held liable in the event of an accident, unless it has failed to take reasonable steps in its duty of care to my child, during the activities and associated travel and\or accomodation arrangements for which it is responsible. I understand that it is my responsibility to advise MSA of any changes in the information I have provided.
Signed (ParentGaurdian)
*
Date
*
-
Month
-
Day
Year
Date
Manchester Storm Academy registered at Planet Ice, Thomas Street Altrincham( “MSA”) is a ‘data controller’ for the purpose of relevant data protection legislation, including the General Data Protection Regulation (“GDPR”) for the information which it collects for recruitment and employment purposes. MSA also acts as a ‘data processor’ on behalf of our members; the EIHAPrivacy Notice is available for viewing if required. I understand that by submitting this form I am consenting to my data being used in this way.
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
My Products
*
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Club Registration Fee
Includes Club Registration Fee
£
15.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Club CPO (Office Use Only)
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