Representative Football Consent & Medical Information Form

Player's Name *

First

Last

Player's Date of Birth *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

This information is required to meet English Schools' FA player registration requirements and in case of emergency

School *

To be eligible to represent Middlesex, players MUST attend school in Barnet, Brent, Ealing, Enfield, Haringey, Harrow, Hillingdon or Hounslow. If their school is not located in one of these boroughs, we CANNOT accept their nomination.

Borough *

Please state the borough in which the school is situated.

Your Child's Year Group *

Please state the CURRENT year group in which your child is in (e.g. Year 9)

If the player is attached to an academy (Cat 1, Cat 2 or Cat 3) please provide details here:

Please provide details of any previous trials the player has had with an academy (Cat 1, Cat 2 or Cat 3)

If the player is attached to an academy development centre or private academy, please provide details here:

If the player is attached to a grassroots team, please provide details here:

Medical Information

Parent / Carer Information

If the player has any injuries, allergies or underlying health conditions, please provide details here:

This information will be kept confidential and only used to provide care if required. It will NOT inform the selection process.

Has the player had a tetanus injection? Please provide details here:

Name of the GP practice with which the player is registered:

Contact details for their GP practice (address, phone number etc:)

Name of Primary Parent / Carer *

First

Last

Email address for Primary Parent / Carer *

Email

Confirm Email

Name of additional Emergency Contact *

First

Last

Email address for additional Emergency Contact *

Email

Confirm Email

Parent / Carer Consent:

I consent to the player named abover participating in Representative Football activities *

Yes

By ticking the box above, you grant permission for your child to take part in trials, Inter-County matches and training sessions as appropriate

I consent to the Middlesex Schools' FA holding and processing personal data for the purposes of Representative Football *

Yes

By ticking the box above, you grant MSFA permission to gather and store the details recorded in this form for use pertaining to Inter-County football. This may include sharing some or all information given here with the English Schools' Football Association. It will NOT be passed by MSFA to commercial entities or other third parties.

This form has been completed by: *

First

Last

Date:

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Medical Information

Parent / Carer Information

Parent / Carer Consent:

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