HF Easter soccer school .pdf

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Happy Feet Soccer School
Dover Athletic Football Club
Crabble Athletic Ground
Lewisham Road, River
Dover, Kent. CT17 0JB




CONFIRMATION AND CONSENT FORM


Easter Holiday Soccer School – ages 5 – 9 year old

th
th
Monday 4 , Tuesday 5 and Wednesday 6th April 2016
Our Easter Holiday Soccer School will run from 10am – 3pm, at a charge of £5 (admin fee.)

Children should arrive no earlier than 9.50am for registration.

Children will need to bring a packed lunch and drinks. Shin pads must be worn at all times.
Spare/warm clothing is advised should we have bad weather as well as sun cream and a hat
should the weather be sunny.
By signing the below confirmation and consent form and returning it to Dover Athletic
Football Club, along with the admin fee of £5, you are applying for a place for your child.
Once your form and payment have been received, you will have the place confirmed by
email. Places will be allocated on a first come first served basis.


Confirmation and consent will only be applicable to the above organised event, any future
club activities will require additional confirmation and consent forms.

This club, in line with our Policy, has been Risk Assessed and checked by Management team.











Happy Feet Soccer School
Dover Athletic Football Club
Crabble Athletic Ground
Lewisham Road, River
Dover, Kent. CT17 0JB

Child’s Full Name ………………………………………….......................................................

Date of Birth
……………………..............................

Address…………………………………………………………………………………………………………………………………
…………………………………………….....................................................................................................
....................................................................................................................................................
.........................................................................................................

Contact telephone number …………...………………..............................................................
Email address …...............................................................................................................

MEDICAL QUESTIONNAIRE

Has your child had any of the following?

Asthma or Bronchitis






YES NO
Heart Condition







YES NO
Fits, fainting or blackouts





YES NO
Severe Headaches






YES NO
Diabetes








YES NO
Allergies to any known drugs or medication



YES NO
Any other allergies e.g. material, food, insect bites etc

YES NO
Other illness or disability





YES NO
Any recent contact with contagious diseases and infections
YES NO
An anaphylactic allergy (e.g. peanuts)



YES NO

If the answer to any of these questions is YES please give details on a separate sheet which
should be firmly attached.




IMMUNISATION STATUS



Has your child received vaccination against Tetanus in the last ten years? YES NO


Are there any other health issues of which we should be aware?


Is your child receiving medical treatment of any kind from either your Family Doctor or
Hospital?










YES NO

Has your child been given specific medical advice to follow in emergencies?
YES NO

If the answer to either question 1 or question 2 is YES please give details here (including
dosage of any medicines/tablets):

This declaration is valid for the dates listed above only.

As numbers are limited for the football club please confirm your child’s place only if you
are certain that they can attend.

It is the Parent/Carers responsibility to inform the Football Club of any changes in
circumstances.

I give my consent for my son/daughter to take part in any such activity and for any
necessary medical treatment, including anaesthetic, to be given resulting from any such
activity.

Signed:

Date: Parent/Guardian

Emergency Contact Details:
(Mobile Number)




DOVER ATHLETIC FOOTBALL CLUB – IMAGE CONSENT FORM
Name of Child: ………………………………………………
Occasionally, we may take photographs of the children during activities. We may use these images on
children’s club promotional material, as evidence for funding projects or on our website and/or social media
accounts. We may also make video recordings for promotional material, monitoring or other educational uses.
From time to time, our club may be visited by the media who will take photographs or film footage of a visiting
dignitary or other high profile event. The children will often appear in these images, which may appear in local
or national newspapers, or on televised news programmes.
Please answer the questions below, then sign and date the form.
Please circle your answer
-

May we use your child’s images
(unidentified) on our website?

-

May we use your child’s images
(unidentified) on our social media accounts
(Facebook, Twitter, Instagram?

-

Yes / No

Yes / No

May we use your child’s photograph
(unidentified) in any printed publications
that we produce for promotional purposes?

Yes / No

-

May we record your child’s image
(unidentified) on video?

Yes / No

-

Do you consent to your child being
photographed or filmed in press events
agreed by the club?

-

Do you consent to photos and videos being
kept at the club?

Yes / No

Yes / No

Please note that websites can be viewed throughout the world and not just in the United Kingdom where UK
law applies. Unidentified means we will only use the first name. Please also note the conditions for use of
these photographs are on the back of this form.
Declaration:
I have read and understood the conditions of use (see below).
Parent’s or Guardian’s signature: _______________________ Date: ____________________________
Name (in BLOCK CAPITALS): __________________________

CONDITIONS OF USE
-



This form is valid for five years from the date you sign it. The consent will automatically expire after
this time. It is your responsibility to let us know if you want to withdraw or change your agreement at
any time.
We, the club, will not use the personal details or full names (which means first name and surname) of
any child in a photographic image on video, on our website, or in any of our other printed publications.
We will not include personal e-mail or postal addresses, or telephone or fax numbers on video, on our
website, or in other printed publications.
If we use photographs of individual children, we will not use the name of the child in the
accompanying text or photo caption, unless we have your agreement.
If we name a child in the text, we will not use a photograph of that child to accompany the article.
We may use group photographs or footage with very general labels, such as “half term club” or “free
kick practice”.
We will only use images of children who are suitably dressed, to reduce the risk of such images being
used inappropriately.
As the child’s parents/guardian/carer, you agree that if you take photographs or video
recordings of your child which include other children, you will use these for personal and
family use only. You understand that where consent has not been obtained from the other parents
for any other use, you would be in breach of the Data Protection Act 1998 if you used your recordings
for any wider purpose.


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