Junior Elks Form
Junior Elks Form
JUNIOR ELKS – ATHLETICS – REGISTRATION FORM
8 Week After School Coaching Programme
(19th January – 9th March 2018)
Fridays: 5-6pm @ Ulster University’s Indoor Track (Jordanstown)
Please complete (both sides) as appropriate using one form per participant.
_______________________________________________ (participant’s name) would like to attend
JUNIOR ELKS - ATHLETICS: Strictly 8-11YRS (Tick)●
Parent / Guardian: ________________________________________________________________
Home Address: ___________________________________________________________________
___________________________________________ Post Code: ______________________
Home Tel: _____________________________ Mobile: _________________________________
Date of Birth: __________________________________________ Age: ________________
Please give the names & contact telephone numbers of two people who may be contacted in case of an emergency:
Name: ________________________________ Name: ________________________________
Tel No: _______________________________ (H) Tel No: _____________________________ (H)
Tel No: _______________________________ (M) Tel No: ______________________________ (M)
I give permission for _______________________________ (insert name) to take part in the JUNIOR ELKS - ATHLETICS After School Coaching Programme. I know of no reason, medical or otherwise why s/he should not undertake the sports and activities involved. I have completed the medical details below and consent that in the event of any illness/accident, any necessary treatment can be administered to my child, which may include the use of anaesthetics. I understand that every possible effort will be made to contact me first. I also understand that while coaches and staff will take every precaution to ensure that accidents do not happen, they cannot necessarily be held responsible for any loss, damage or injury suffered by my child.
I am willing to let my child participate in any official media coverage required (Tick) ●
(Individual Cost: £28.00Discount for 2nd Child: £24.50)
I have enclosed £ _____ to cover the cost of the coaching sessions. NB Please do not send cash. Cheques should be made payable to the Ulster University Sports Development
Payment may also be made by credit/debit card by telephone or in person at Sports Centre Reception.
Signed: ___________________________________________________ (Parent/Guardian) Date: _________________
MEDICAL DETAILS (Please complete as appropriate)
Doctor’s Name: Dr. ___________________________ Telephone: __________________________
Has your child had a tetanus injection in the last 10 years? Yes / No
In your child’s interest it is important that we know whether s/he suffers from any illness or medical condition. Please use the following space to state, in confidence, any health or other matters concerning your child about which we should be aware e.g. allergies. Please also indicate if your child is receiving any medication, with details and dosage and any specific dietary requirements.
Completed registration forms should be returned with the appropriate payment to:
Junior Elks - Athletics
Cancellation Procedure: Other than in exceptional circumstances, camp refunds will not be issued.