Colts Player Profile Form Section 1: Personal details of the player and their parent or legal guardianName of Player(Required) First Middle Last Date of Birth(Required) DD slash MM slash YYYY Name of Parent or Legal Guardian(Required) First Last Home Address(Required) Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country School of Child(Required) Age Group(Required)Under 8Under 9Under 10Under 11Under 12Under 13Under 15Under 17Under 19School Year(Required)45678910111213Email Adress Parent(Required) Email Address Child(Required) Home Phone(Required)Work PhoneMobile Phone(Required)Section 2: Emergency contact detailsIn the event of an incident or emergency situation, where a parent or legal guardian named above cannot be contacted, please provide details of an alternative adult who can be contacted by the club. Please make this person aware that his or her details have been provided as a contact for the club: Name(Required) First Last Phone Number(Required)Relationship to Child(Required) Section 3: DisabilityDo you consider your child to have a disability?(Required) Yes No What is the nature of their disability?(Required) Visual impairment Hearing impairment Physical disability Learning disability Multiple disability Other Please Specify Other Specify(Required) Section 4: Medical InformationPlease detail below any important medical information that our coaches need to know (e.g allergies, medical conditions, current medication, special dietary requirements, injuries, etc)Details(Required)Name of Doctor(Required) First Last Surgery(Required) PhoneSection 5: Consent Statement to be completed by Parent or Legal GuardianLegal Authority to provide consent:(Required) I confirm that I have legal responsibility for the child named above and I am entitled to give this consent.Accurate Info Consent(Required) I confirm that to the best of my knowledge, all information provided on this form is accurate, and that I will undertake to advise the club of any changes to this information.(Required)Consent to participate:(Required) I agree to the child named above taking part in activities of the clubMedical Consent:(Required) I give my consent that in an emergency situation, the club may act in loco parentis, if the need arises for the administration of emergency first aid and / or other medical treatment which in the opinion of a qualified medical practitioner may be necessary. I also understand that in such an occurrence that all reasonable steps will be taken to contact me or the alternative adult which I named in section 2 of this form.Medical Consent(Required) I confirm that to the best of my knowledge, my child does not suffer from any medical condition other than those detailed by me in section 3 & 4 of this form.(Required)Policies Consent(Required) I confirm I have read, or been made aware of the clubs policies concerning: (Note these are displayed on the clubs notice board.)(Required)Untitled(Required) Changing and Showering Transport Photography / Video Managing Missing Children Children Playing in adult matches Anti bullying and the code of conduct Select AllPhotography Consent(Required)I consent to the club photographing or videoing my child’s involvement in cricket under the terms and conditions in the club photography / video policy Yes No Data ProtectionThe club will use the information provided on this form (together with other information it obtains about the player) to administer his/her cricketing activity at the club any in any activities in which he/she participates through the club and to care for and supervise activities in which he/she is involved. In some cases this may require the club to disclose the Information to County Boards, Leagues and to the England and Wales Cricket Board. In the event of a medical issue or child protection issue arising, the club may disclose certain information to doctors or other medical specialists and/or to police, children’s social care, the courts and/or probation officers to legal and other advisers involved in an investigation. As the person completing this form you must ensure that each person whose information you include in this form knows what will happen to their information and how it maybe disclosed.