Membership Number: *

Player Name: *

Date of Birth: *

Age Group: *
Mini TotsUnder 4'sUnder 5'sUnder 6's
Full Address and Postcode: *

Parent Email Address: *

Parent Telephone: *

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

Nationality: *

Ethnicity: *

Payment Options:*
£90 Annually3 Payments of £35 (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 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