Please enable JavaScript in your browser to complete this form.Players Name *FirstLastDate of Birth (dd/mm/yyyy) *Nursery/School (if applicable)Medical & Health Declaration:: Does Your Child a Medical/Health Condition *YesNoPlease give details of any Medical/Health Conditions of Your Child. *Add Another PlayerTick Yes to addName of Second Player *FirstLastDate of Birth of Second Player *Pre-School/School of Second Player *Medical & Health Declaration: Does Your Second Child have a Medical/Health Condition *YesNoPlease give details of the Medical/Health Condition of your Second Child. *Add a Third PlayerTick Yes to addName of Third Player *FirstLastDate of Birth of Third Player *Pre-School/School of Third Player *Medical & Health Declaration: Does Your Third Child a Medical/Health Condition *YesNoPlease give details of the Medical/Health Condition of your Third Child. *Parent and Guardian InformationParent/Guardians Name (Primary) *FirstLastPhone No. *Email *Parent/Guardians Name (Scondary) *FirstLastAlt. Phone No. *Email *Primary Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeDonation & Gift Aid (Optional)If you wish to make a donation to the Club Legacy Fund and claim Gift Aid, you can do so below:Make a Legacy Fund DonationNoYes (£25.00)Yes (Other)The Clubs current fund raising drive is for the Legacy Fund. The fund will be used to provide security for future rugby player generations by extending the lease of the rugby club grounds and facilities. The current lease runs out in 2045 and we wish to extend this to 2075Your Donation Amount: *Community Amateur Sports Club (CASC) Gift Aid for Westcliff Rugby Football Club Limited (Optional)Yes, I want to Gift Aid my donationNo, thank youIf eligible, Gift Aid can boost your donation by 25p for every £1 donated.Gift Aid Eligability & Commitment *Yes, I am a UK taxpayer and I understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all of my donations in that tax year it would be my responsibility to pay any differenceHigher or additional rate payers who want to receive additional tax relief due to you should include all Gift Aid donations on you Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code. My Future Donations to Westcliff Rugby Football Club Limited (Optional)I want to Gift Aid my future donations to Westcliff Rugby Football Club LimitedPlease notify the CASC if you want to cancel the declaration; changed your name or home address, or no longer pay sufficient tax on your income and/or capital gains.Declaration of ConsentMedical Treatment *I give my consentIn the event of injury / illness that may require medical treatment or use of anesthetic I agree to the Team Coach/Manager signing the necessary consent formPhotograph/Video Taking & Publication *I give my consentI confirm my consent to photographing/videoing and publication of images of my child whilst participating in rugby activityFair Play for All Code of Conduct *I agreeI have read and agree to follow the club Fair Play for All Code of Conduct Document and will ensure that I draw this to the attention of my childClub e-News Letter (Optional)I give my consent I give my consent for the club to send me "The Westcliff Word", the club e-News Letter via Mail Chimp which contains news, events, and links to sponsors websites. Mail Chimps privacy policy can be found by following the link: https://mailchimp.com/legal/privacy/ the news letter will also be published on the clubs website, and your consent can be removed at any time by selecting the Unsubscribe link on the publication, or by contacting the Clubs Data Officer.Club Lunch, Dinnner and Other Event Notifications (Optional)I give my consent I give my consent for the club to send me notifications via e-mail of planned lunches, dinners and other events Events will also be published on the clubs website, and your consent can be removed at any time by contacting a member of the Clubs Hospitality team.Signature *Clear SignaturePlease draw your signature on the touch screen or by using the mouse. When using a mouse, hold down the left button to draw.Date / Time *Captcha * = Please enter your answer in the box above. Please remember "*" is multiply and "/" is divide.Submit
