LOASS FC
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Contact and Consent Form 2016-17
Team
*
Indicates required field
Age
*
U7
U8
U9
U10
U11
U12
U13
U14
U15
U16
U18
Gender
*
Boys
Girls
Team Name
*
Spitfires
Hurricanes
Tornadoes
Player details
Player First Name
*
Player Surname
*
Player Date of Birth dd/mm/yyyy
*
Player/Contact Email
*
1st Line of Address
*
House/Flat Number and Street
2nd Line of Address
*
Town or City
Postcode
*
Player/Contact Tel Number
*
Standing order reference
*
Please enter Standing order reference if known
Parent/Carer Details
1st Contact title
*
Mr
Mrs
Ms
Miss
1st Contact First name
*
2nd Contact Title
*
Mr
Mrs
Ms
Miss
2nd Contact First name
*
1st Contact Surnane
*
1st Contact Mobile Number
*
1st Contact Email
*
2nd Contact Surname
*
2nd Contact Mobile Number
*
2nd Contact Email
*
1st Contact Address As Above
*
Yes
No
2nd Contact Address As Above
*
Yes
No
School details
School Name
*
School Telephone Number
*
School Address
*
School Postcode
*
Doctors Details
Doctors Name
*
Doctors Address
*
Doctors Telephone Number
*
Doctors Postcode
*
Please state if you have any medical condition that you think we should be aware of:
*
State 'None' otherwise
Please state if there are any special requirements you have regarding diet:
*
State 'None' otherwise
Please state of any other considerations with regard to your child.
*
State 'None' otherwise
CONSENT TO PHOTOGRAPH - Video/Photo Release Authorisation
I give permission to LOASS FC and/or parties designated by LOASS FC to photograph the person named above and use such photographs in all forms of media, for any and all promotional purposes including advertising, display, audio visual, exhibition or editorial use.
I further consent to the use of the name of the person named above in connection with the photographs if needed by LOASS FC.
Photo/Video Consent
*
Yes
No
THIRD PARTY INFORMATION
The information you provide will be held in strict confidence by LOASS FC. I consent to my details being forwarded upon request to professional football clubs and the Football Association which will only include the player’s contact and ethnicity details.
Third Party Information Consent
*
Yes
No
CONSENT DECLARATION
I give permission for my child to take part in this activity that may also involve trips organised by LOASS FC and I am willing for LOASS FC volunteers to act on my behalf for the welfare of my child in the event of an emergency. We agree to stand by the LOASS FC rules and adhere to its Code of Conduct, including ensuring all fees are paid on time and understand that failure to do so will result in disciplinary action being taken which could result in your child being suspended from playing any organised football. I understand that I will not be offered a refund for registration or monthly fees should my child(ren) decide to leave LOASS FC throughout the season.
Please tick the consent checkbox below and submit the form by clicking the submit button
Consent declaration
*
I agree to the consent declaration
Gift Aid
Gift Aid
*
I want to gift aid my signing on as a donation
Please consent to Gift Aid if you are a UK taxpayer and understand that if you pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all your donation it is your responsibility to pay any difference.
Gift Aid can be reclaimed by LOASS FC through the charity ASSA (Charity No. 1145070
)
from the tax you pay for the current tax year.
Your address is needed to identify you as a current UK taxpayer.
If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.
Please notify us if you:
- want to cancel this Gift Aid declaration
- change your name or home address
- no longer pay sufficient tax on your income and/or capital gains
If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.
Submit
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