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Tottonians Rugby Club Membership Details & Medical Information Season 2017/2018 Membership £60 (per family) Colts free Cheques Payable To TRFC Mini/Junior

Squad ...................... Reg No..................... Receipt No............... CSH / CHQ / CARD

Player’s Name........................................................................Date of Birth.................................Age............. Home Address................................................................................................................................................ ...........................................................Post Code............................ Home Telephone No.............................. School.................................................................................Year.......................Plays at School YES / NO Contact 1

Contact 2

Contact 3

Relationship to Child Full Name Mobile No. Email Address

Medical Information. This information is requested to ensure that the player receives the correct medical attention. This information is held by the Junior Section Secretary and the team coach. Does the above player have any medical conditions or allergies YES / NO

If YES please give details.......................................................................................................................... Regular medication................................................................................................................................... Additional medication in the event of a medical incident? EG Inhaler or Epi Pen or Other YES / NO

Details.............................................................................................................................................................. I give my permission for photographs/videos to be taken of my child and used by Tottonians RFC and or Hampshire RFU (Please delete this paragraph if you do NOT agree). I give my permission for my son/daughter to participate in Rugby training, matches and events organised by Tottonians Rugby Football Club.

Name...................................................Signature........................................................Date........................ Players Signature........................................................................................................................................ Tottonians Rugby Club Water Lane Totton SO40 3GX 023 80663810 www.tottonians.com