Membership Number: *

Player Name: *

Date of Birth: *

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

Parent Email Address: *

All parent email addresses will be put into our Parent's mailing list and you will receive an email asking for your confirmation. To remove your email address from our Parent's mailing list later, please select Parent's Mailing List under Registrations.

Parent Telephone: *

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

Nationality: *

Ethnicity: *

Please make payments via BACS/ Bank 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 email treasuer@middletonparkfc.co.uk.

Medical Conditions: *

Allergies: *

Emergency Contact Name: *

Emergency Contact Number: *

Relationship to Player: *

Tick this box if you registered with us last season.

* 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