REGISTRATION DOCUMENT

PLEASE COMPLETE ALL SECTIONS LEGIBLY

FIRST NAME………………………………………………………………………………………………..

SURNAME………………………………………………………………………………………………………

DATE OF BIRTH……………………………………………………………………………………….

ADDRESS (IN FULL)……………………………………………………………………………………

…………………………………………………………………………………………………………………………

POST CODE………………………………………………………………………………………………

HOME TELEPHONE NUMBER………………………………………………………………

EMERGENCY TELEPHONE NUMBER……………………………………………………….
(DIFFERENT FROM ABOVE)

NAME OF EMERGENCY CONTACT………………………………………………………….

EMAIL ADDRESS………………………………………………………………………………………….

MEDICAL CONDITIONS OF WHICH WE SHOULD BE AWARE

…………………………………………………………………………………………………………………………..

SCHOOL ATTENDING………………………………………………………………………………..

DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY, IF SO WHAT?

PHYSICAL/LEARNING/HEARING/VISUAL/OTHER (GIVE DETAILS IF OTHER)

……………………………………………………………………………………………………………………………….

WHAT IS YOUR ETHNICITY?

WHITE/MIXED/ASIAN OR ASIAN BRITISH/ BLACK OR BLACK BRITISH/

CHINESE OR OTHER ETHNIC GROUP

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SUPPLYING THE FOLLOWING INFORMATION IS COMPLETELY OPTIONAL.

Parent/carer 1

Name:

Employer:

Job title:

Main employment skill:

Parent/carer 2

Name:

Employer:

Job Title:

Main employment skill:

I hereby give permission to Shrewsbury Rugby Club to take and retain photographs of my son/daughter, provided that my said son/daughter is a member of Shrewsbury Rugby Club Junior Section and such photographs are only to be used for promoting Shrewsbury Rugby Club in a sensible and responsible manner either at the Club or in appropriate newspaper and/or magazine articles.

I acknowledge that such permission is only given for the 2007/2008 season and can be withdrawn by me, my son/daughter or any adult who acts as carer for my son/daughter by giving notice in writing to the Junior Club Secretary and delivering the same to the Clubhouse.

……………………………………………………………………… Signature of parent

……………………………………………………………………….Name of child