Sporting Memories

Sporting Memories

The information given below will be keptconfidential and only seen by the facilitators of the club and staff within Sporting Memories and Somerset CricketFoundation. The information provided will be used to help Somerset Cricket Foundationin the case of an emergency should you become unwell. The details alsogive us the opportunity to find out about your interests and hobbies, so that we can make the sessions as interesting as possible for you. It will alsoprovide a baseline of information as part of the funded projects evaluation.Permission has been granted and authorised forthe club facilitator to call the named personnel or the emergency serviceswhere required, and appropriate in relation to the wellbeing of theparticipant. (See Emergency Contact details).
Your contact information
Name*

First NameLast Name
Email address*
example@example.com
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Which session would you like ot attend?*

BridgwaterUphill CastleMinehead

Medical information
Do you have any of the following:*

Physical/Mobility issuesHearing LossMental health issuesSight LossLearning difficultyNone of the aboveHeart conditionOther
PLEASE LIST ANY DISABILITY OR HEALTH CONDITION THAT WE NEED TO BE AWARE OF:
CURRENT MEDICATION/TREATMENT

Photographic consent
PHOTOGRAPHIC, VIDEO IMAGES AND AUDIO CONSENT: BOTHPARTNERS PRODUCE A WIDE RANGE OF MATERIALS TO INFORM PEOPLE ABOUT OUR WORK SUCHAS PRINTED PUBLICATIONS, ADVERTS, AUDIOVISUAL AND ELECTRONIC MATERIALS, MEDIAWORK, DISPLAY AND ANY OTHER MEDIA THAT WE MAY USE IN THE FUTURE. THE COPYRIGHTOF ANY MATERIAL WHICH IS GENERATED AS A RESULT SHALL BE ASSIGNED AND SHALL BETHE PROPERTY OF REMINISCENCE LEARNING AND SOMERSET CRICKET FOUNDATION. DO YOU GIVEPERMISSION FOR PHOTOGRAPHIC, VIDEO IMAGES AND AUDIO CONSENT

YesNo

Would you like to receive the Foundation's friendly newsletter?*

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Your contact information