Portsmouth & Southsea Cricket Club
Membership Form 2008
http://www.pscc.play-cricket.com/
To ensure that we have the correct contact details for Players, please insert the information requested below and return this form to: -
The Treasurer
Portsmouth and Southsea Cricket Club
45 Locarno Road
Copnor
Portsmouth
PO3 5DG
If you are under 18 please also ask your Parents or Guardian to sign this form before it is returned.
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surname
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FIRST NAME
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DATE OF BIRTH
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CONTACT DETAILS
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ADDRESS
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POSTCODE
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HOME TELEPHONE
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MOBILE TELEPHONE
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WORK TELEPHONE
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EMAIL ADDRESS
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NEXT OF KIN
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DOCTOR/GP
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DOCTOR’S
TELEPHONE
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PLEASE NOTE
The Club cannot accept responsibility for the loss or damage of personal property during practices or matches.
The Club holds certain data relating to each member. This data is purely of an administrative nature and is to ensure the smooth running of the Club. Statistical data collected for each member will continue to be published on the Club’s website.
Would all members over the age of 18 complete the attached Self Declaration and return to in a sealed envelope to Ian Power the Club Welfare Officer. Alternatively please return to the Treasurer who will ensure it is forwarded in confidence.
SUBSCRIPTIONS
All players are required to pay an Annual Subscription Fee of £60.00 (£30 for those in full time education) to Portsmouth and Southsea Cricket Club. Subscriptions are due and payable before the commencement of the league playing season (1Sst May 2008) and do not cover match fees and practice costs.
DECLARATION
On election to Membership I undertake that I will pay the Annual Subscription Fee (as shown above) and to abide by the rules of conduct and laws of the game as laid down by the Club and the England and Wales Cricket Board.
SIGNED…………………………………………………. DATE ………………………………………..
SIGNED…………………………………………………. (PARENT/GUARDIAN)
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Portsmouth & Southsea CC
Self Declaration Form
CONFIDENTIAL
Part A
If you need more space to enter your details, or wish to give additional information, please use a separate sheet.
PERSONAL DETAILS
Surname: __________________________________________________________
First Name(s): ______________________________________________________
Address: __________________________________________________________
________________________________________ Postcode: ________________
E-Mail: ____________________________________________________________
Home telephone number: _____________________________________________
Mobile telephone number: _____________________________________________
With discretion, may we contact you at work? ______________________________
Work telephone number: ______________________________________________
Please list any previous clubs that you have played/worked/volunteered for:
1. _______________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
5. _______________________________________
CONFIDENTIAL
Part B
The England and Wales Cricket Board (ECB) and affiliated cricketing organisations, including this Cricket Club, aim to promote equality of opportunity for all persons and welcome participation from a wide range of individuals, including those with prior criminal records. The membership/voluntary position for which you have applied is an exempted occupation for the purposes of the Rehabilitation of Offenders Act 1974 (as amended by the Rehabilitation of Offenders Act 1975). All ‘spent’ and ‘unspent’ convictions must be declared. Having an ‘unspent’ conviction will not necessarily impede your involvement with Cricket: this will depend on the circumstances and background to your offence. If you fail to disclose an offence and the ECB or any affiliated organisation is later informed of any undisclosed criminal matter, you may be subject to disciplinary action. Evaluation of information is based on strict confidentiality and discretion.
1. Have you ever been convicted of any criminal offences or accepted any reprimands or cautions or Police warnings?
Yes No
If yes, please supply details of any criminal convictions:
__________________________________________________________________________
2. Are you a person known to any Social Services department as being an actual or potential risk to Children or Young People?
Yes No
If yes, please supply details:
__________________________________________________________________________
3. Have you ever had a disciplinary sanction (from any sports or other organisation’s governing body) relating to child abuse?
Yes No
If yes, please supply details:
__________________________________________________________________________
I understand that it is necessary for me to declare any information requested and that the membership/voluntary position for which I have applied may involve access to Children, Young People and/or Vulnerable Adults. I hereby give my consent to the ECB for it to conduct a Criminal Records Bureau (CRB) check if so required. The ECB Child Protection Manager may be informed of disclosed information.
Name: __________________________________________Date of Birth: __________________
Signature: ______________________________________ Date: ________________________
Please return this form to Club Welfare Officer – Ian Power
Please mark the envelope ‘Private and Confidential – SDF’