Membership

Activity Consent Form 17/18

Youth

Great Britain Wheelchair Rugby

ACTIVITY CONSENT FORM 17/18: YOUTH

Participant details
First name:
Last name:
Address:
Date of birth:
Age during activity:
The above named person has approval to participate in:
GBWR Season 2017 – 2018 (31st July 2017 – 31st July 2018)
Parent / legal guardian Agreement
Ages 12 – 17 years (inclusive) are eligible for Youth Membership (including participation in adult training and competition) subject to the following criteria being agreed to and met. Parent / legal guardian to tick alongside each criterion to confirm provision of documentation or acceptance of terms.
☐ / Completion of the ‘Renewals 17/18’ form for renewing GBWR Members or completion of the ‘New Members 17/18’ form for those registering with GBWR for the first time
☐ / Completion of the ‘Activity Consent Form 17/18: Youth’ by a parent or legal guardian of the child
☐ / Provision of a copy of proof of ID of the young person
☐ / Club Welfare Officer’s acknowledgement of young person at club
☐ / Doctor’s note detailing medical suitability for the game of wheelchair rugby and any concerns which should be raised prior to participation.*
*As a minimum, this should be dated no earlier than 6 months prior to the date of membership application, and must state that there is no medical reason why the young person cannot play wheelchair rugby.
☐ / At any training session or competition participated in by a young person, parent / legal guardian to be present if aged 12 – 15 years (inclusive), and responsible adult (as agreed by the CWO and parent / legal guardian) present if aged 16 – 17 years (inclusive)
☐ / Understanding of parent / Guardian that the young person will have to go through the ‘Fit to Play’ process to determine their suitability to train and compete with and against adults. The young person will not be allowed to compete in adult competition until they have gone through the process
☐ / Use only of adult specification chairs (at youth appropriate sizes) when participating with adults
☐ / Understanding of parent / guardian that in any competition the match officials retain the right to stop a game and halt a young person’s participation if they feel that a young person is at risk
☐ / Parent / legal guardian has been made aware by Youth Programme Manager that a successful application will permit the young person to participate alongside adults at an adult level.
I understand that participation in wheelchair rugby activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Great Britain Wheelchair Rugby, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organisations associated with the activity from any and all claims or liability arising out of this participation.
In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission for the above named person to be taken to an appropriate medical facility.
Participant’s signature / Date
Parent / legal guardian name (printed)
Parent / legal guardian signature / Date
Parent / legal guardian telephone number
Parent / legal guardian e-mail address
Photography Authorisation
I hereby authorise Great Britain Wheelchair Rugby, hereafter referred to as ‘GBWR’, to publish photographs taken on (______) of myself and/or the child or children listed below, and our names and likenesses, for use in GBWR's print, online and video-based marketing materials, as well as other GBWR publications. I hereby release and hold harmless GBWR from any reasonable expectation of privacy or confidentiality for myself and for the child and children listed below associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child or children listed below and that I have full authority to consent and authorise GBWR to use their likenesses and names.
I further acknowledge that participation is voluntary and that neither I, the child, nor children will receive financial compensation of any type associated with the taking or publication of these photographs or participation in GBWR marketing materials or other GBWR publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release GBWR, its contractors, its employees and any third parties involved in the creation or publication of GBWR publications, from liability for any claims by me or any third party in connection with my participation or the participation of the children listed below.
Please select one option: / For self as adult / As parent/guardian of child / Both
Name (printed
Signature: / Date:
Address:
Telephone: / Email:
Child Details
Names and ages of child or children:
Name:
Age:
Authoriser’s relationship to child:
Name:
Age:
Authoriser’s relationship to child:
Name:
Age:
Authoriser’s relationship to child:
Name:
Age:
Code of Conduct
GBWR is committed to appropriate behaviour as outlined within our Codes of Conduct, which are available in full at or by contacting the GBWR Head Office.
☐ / I confirm that I have read and agree to abide by all GBWR Codes of Conduct, as applicable dependent upon my role(s) within the sport.
GBWR Agreement
Head Office to tick alongside each criterion to confirm provision of documentation evidencing the below confirmations.
☐ / GBWR Lead Safeguarding Officer and Youth Programme Manager agreement (including review of child and club suitability) for young person’s participation
☐ / GBWR Chief Executive approval
The completed form should be returned to or posted to:
GBWR, Rugby House, Twickenham Stadium, 200 Whitton Road, Twickenham, TW2 7BA

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