Z Test Form

POULTON CRICKET CLUB SENIOR MEMBERSHIP APPLICATION FORM

(For players over the age of 18)

This form is designed to be completed by a player over the age of 18. If you are under 18, please use the Club’s Junior Membership Application Form instead.

As the person completing or receiving this form, you must ensure each person whose information you include in this form knows what will happen to their information and to whom it may be disclosed. Details are set out in the Privacy Notice section of this website.

The Club uses the ECB’s Play-Cricket system and the SPOND Application to store data. Data from this form may, therefore, be entered onto that system.

SECTION 1 (MANDATORY): PERSONAL DETAILS OF PLAYER / OFFICIAL

All information in Section 1 will be used by the Club and provided to the ECB and will be used and protected as described in the Privacy Notice section of this website.

Player Name

Gender

Home address

Post code

Date of birth

Email address

Home telephone number

Mobile telephone number

Are you interested in playing League cricket

Yes

No

If you answer YES, should you be selected by the Club to play for us in a League requiring player registration, relevant information from Section 1 (including month and year of birth) will be provided to that League to enable them to check your eligibility to play in that League.

If you are or become an official of the Club, the Club may provide the information in Section 1 to County Boards or Leagues that the Club is a member of or affiliated to in order to allow them to contact you about cricket matters.

If you are a player and attend a County Board or League run event (such as trials, nets or representative fixtures), the Club may provide your name and contact details to the relevant League / County Board to enable them to notify you of arrangements.

Name of an adult who can be contacted in an emergency

Telephone number of named adult

Relationship which this person has with you

SECTION 3 (OPTIONAL): SPORTING EXPERIENCE INFORMATION

Have you played cricket before?

Yes

No

If you have played before, where did you play?

Club

School

University

Local authority coaching session(s)

Other (please specify)

SECTION 4 (OPTIONAL): DISABILITY

By providing the information in Section 4, you are giving your explicit consent to the Club using this information (and any additional disability information provided by or for you) for statistical purposes as well as to establish if there are any needs / support / adjustments that you may require.

The Equality Act 2010 defines a disabled person as anyone with a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.

Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last 12 months or more?

Yes

No

Does this disability or illness affect you in any of the following areas?

Vision impairment

Hearing impairment

Mobility impairment

Dexterity impairment

Learning impairment

Memory impairment

Mental health impairment

Stamina, breathing or fatigue impairment

Development impairment

Another type of impairment - please provide more details

SECTION 5 (OPTIONAL): MEDICAL INFORMATION

By providing the information in Section 5, you are giving your explicit consent to the Club using this information (and any additional medical information provided by or for you) to help you when you participate in cricket activities.

Please detail below any important medical information that our Club volunteers need to know and which would be affected by your participation in cricket activities. Such information includes alergies; medical conditions (for example epilepsy, asthma and so on); current medication; special dietary requirements; any additional needs and/or any injuries.

Please indicate if you would like to discuss this privately with us.

Name of doctor / surgery name

Doctors telephone number

I consent to my medical details being shared with coaches/leaders for the purposes of the delivery of my safe participation in Club activities

If you do not give your consent, this will not affect your membership of the Club. However, giving us consent to share this information will help Club coaches and leaders know how to respond effectively in the case of any medical emergency.

SECTION 6 (MANDATORY): PLAYER PARTICIPATION AGREEMENT

I agree to take part in Club activities

I confirm that I have read, or have been made of, the Club policies concerning:

Changing / showering

Anti bullying and the code of conduct

Transporting children

Photography / video

Social media, text and email

I understand and agree to the responsibilities which I have regarding these policies

SECTION 7 (OPTIONAL): CLUB PHOTOGRAPHY / VIDEO CONSENT

I consent to the Club photographing or videoing my involvement in cricket in line with the Club photography/video policy

If you do not give your consent, this will not affect your membership of the Club. If you choose not to give consent, please contact us to discuss how we can manage any potential photography.

SECTION 8: PRIVACY STATEMENT

Poulton Cricket Club takes the protection of the data that we hold about you as a member seriously and will ensure that the data you provide is processed in accordance with data protection legislation.

Please read the Clubs Privacy Notice on this website carefully to see how the Club will use and protect your personal data, who it may be disclosed to and why and your rights in respect of your personal data.

PLAYER DECLARATION

At a rate of 25% Gift Aid is reclaimed by Poulton Cricket Club as a registered charity from the tax you pay each year. Your Address is used to identify you as a current UK Tax Payer.

By consenting in the following box, you confirm you are a UK taxpayer and understand that if you pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all your donations in the tax year it is your responsibility to pay any difference. You also consent that all donations you make in the future or have made in the past four years will be covered by Gift Aid

Gift Aid Confirmation

I confirm I would like to opt into Gift Aid

I do not wish my donations to be covered by Gift Aid

By submitting this form, I confirm that I have read and understood the permission statements on this form and the Privacy Notice section of this website

Player signature (please enter your name below)

Date of submission