Membership Numbers: *

Player Name: *

Date of Birth: *

Age Group: *
Under 7'sUnder 8'sUnder 9'sUnder 10'sUnder 11'sUnder 12's
Full Address and Postcode: *

Parent Name: *

Parent/Player Email Address: *

Opt-in to our Parents Mailing List:
Parent/Player Telephone: *

Player Gender: *
MaleFemalePrefer not to say
Country of birth: *

Nationality: *

Ethnicity: *

Payment Options:*
£150 Annually3 Payments of £55 (End of July, Sept and Nov)

Payment Method:*
We would prefer to be paid via BACS transfer: Account Name: Middleton Park Juniors, Account No: 34940219, Sort Code: 05-00-90, Reference: (This should be your membership number)

If this isn't possible, please select an option below.

BACSCashCheque (Payable to 'Middleton Park Juniors')PayPal (Select Pay a Friend: treasurer@middletonparkfc.co.uk)

Medical Conditions: *

Allergies: *

Emergency Contact Name: *

Emergency Contact Number: *

Relationship to Player: *

* I herby agree that any kit provided will be returned at the end of the season or if the player leaves the club. I understand that failure to return the supplied kit will incure a fee of £35.00 for the replacement.

* I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time. I agree to abide to the clubs rules, codes of conducts and policies and to ensure my family and friends will do so too or the committee reserves the right to suspend my membership.

Note: Fields marked with * are required