Soccer School – Direct Debit Payment Plan COALVILLE TOWN YOUTH SOCCER SCHOOL Player Details Player Name (required) Player DOB (required) Player School Year(required) Player Address (required) Player Address Post Code (required) Parent/Guardian Details/Emergency Contact Details Parent/Guardian Details/Emergency First Name (required) Parent/Guardian Details/Emergency Surname Name (required) Parent/Guardian Details/Emergency Phone No. (required) Parent/Guardian Details/Emergency Email Address (required) Second Emergency Contact Name (required) Second Emergency Contact No (required) Second Emergency Relationship to Player (required) Medical Conditions Details Does the player have any medical conditions you feel the club need to be aware of? YesNo if Yes, please fill in below details; Medical Condition; Doctors Name (required if Yes) Doctors Address (required if Yes) Doctors Phone No (required if Yes) PLEASE READ Photographs may be taken of your child playing for Coalville Town Youth FC, Please tick if this is acceptable as we may use these photographs for publicity and promoting the club. YesNo We love to send you details about up and coming events,offers and the latest info from Coalville Town Youth Football Club by email, SMS and other electronic means. We'll always treat your personal details with the upmost care and never sell them on to other companies for marketing purposes. Yes - PleaseNo - Thanks Membership Terms and Conditions - Read and Understand View Code of Conduct I have read and understood the FA Respect Code of Conduct for Young Players, Spectators/Parents/Carers and the policies of the club and I will follow the Code of Conduct and Club policies at all times.If I do not follow the Code of Conduct and Club policies, I am aware of the possible actions by Coalville Town and the FA Read & Understood If mine/parent/guardian behaviour causes the club to incur fines then you will deemed liable for the associated costs. Any outstanding debts/fines may cause the player to be inegliable to play for the team until such time debts/fines have been cleared. Read & Understood Payment Type Cost Monthly Direct Debit Fee (7th of each month) £15.00 per calendar month Cost includes after three full payments player will receive free training kit Direct Debit link will be emailed once registration form has been validated by our registration team Please check your details are correct before submitting this form. Any missing information will hold up registration of player I confirm that the information given in this form is true, complete and accurate. Direct Debit Option