Contact and Consent Form

LOASS FC

Contact and Consent Form 2016-17

Team

* Indicates required field

Age *

Gender *

Team Name *

Player details

Player First Name *

Player Surname *

Player Date of Birth dd/mm/yyyy *

Player/Contact Email *

1st Line of Address *

2nd Line of Address *

Postcode *

Player/Contact Tel Number *

Standing order reference *

Parent/Carer Details

1st Contact title *

1st Contact First name *

2nd Contact Title *

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: *

Please state if there are any special requirements you have regarding diet: *

Please state of any other considerations with regard to your child. *

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