From the Mosque
Boy's Rugby
Name (of young person)
*
First Name
Last Name
Address (of young person)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (of parent or guardian)
*
-
Area Code
Phone Number
Email (of parent or guardian)
*
example@example.com
Young persons age:
*
Emergency Contact Details:
Please provide the details of two adults that can be contacted in the case of an emergency
Name
First Name
Last Name
Relationship to young person:
*
Phone Number
*
-
Area Code
Phone Number
Name
*
First Name
Last Name
Relationship to young person:
*
Phone Number
*
-
Area Code
Phone Number
Does the young person have a medical condition, disability or neurodiversity that we should be aware of? Please include any allergies or current medications taken here.
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Monitoring and Evaluation
Do you currently play sport outside of school time?
*
Yes
No
If you answered yes, how many days per week do you play sport outside of school?
1
2
3
4
5
6
7
If you answered yes, what other sports do you currently play?
Given the opportunity would you be interested in taking part in any of the following sports?
*
Skateboarding
Boxing
Table Tennis
Judo
Football
Mixed Martial Arts
Swimming
None
Other
If you selected other please state here:
Parental Consent
This is to be completed by parents or guardians for those below 16 years.
Please tick this box to provide your consent for us to occasionally photograph and/ or film your child participating in our activity sessions. These photos and/or films may be used for promotional purposes and feature across our marketing platforms including but not limited to: AHR Inclusion Ltd website and AHR inclusion Ltd social media platforms. These photos may also be shared with third parties for their promotional purposes. AHR inclusion Ltd takes its responsibilities under the Data Protection Act 1998 seriously. The information provided by you is collected to enable us to analyse participant data.
Yes
No
Submit
Should be Empty: