Football Academy

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Emergency details

Contact 1

Name *

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Contact 2

Name *

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Your GP

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Medical information

Do you have:

Asthma

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Are you currently taking any medication? *

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Have you had a tetanus injection in the last 5 years? *

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Do you consider yourself to have a disability? *

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General information

How did you find out about RPT?

Why do you want to attend RPT?

Is there anything we can help with?

What are your hobbies and interests?

What are you plans for the future?

I consent to my child participating in RPT activities. I also consent to my child being escorted by RPT to and from activities on the programme by vehicle both public and private and as a pedestrian. I recognise that the accompanying staff will be responsible for their supervision and care as far as I can be reasonably expected. I understand that they may not be constantly supervised. I acknowledge the need for mature and responsible behaviour of my child and I believe that this can be expected from them. I agree that my child has read and understood the terms & conditions of membership and agrees to abide by these and any decision made by RPT.

I agree to inform the RPT in writing as soon as possible of any changes to the person named above medical circumstances either prior to or during the programme. I agree that in an emergency the RPT or its representatives may authorise medical treatment for my child including anaesthetic, if it is not practical to consult me or the emergency contacts first. I will indemnify the project and its representatives, agents and employees from any responsibilities given to them, in relation to acting in "loco-parentis" in the case of medical emergencies only.

I agree to indemnify the project, its representatives, agents and employees from all liabilities in relation to loss or damaged suffered or caused by my child which result in other than negligence of the project or their representative or which result in my child failing to follow any reasonable instructions given to them.

I understand that photographs, audio and visual recordings of members engaged in activities at RPT may be used for promotional purposes only including social media.

I do not give permission for this

I understand that the information given maybe kept on a computer database which will only be accessed by RPT and information shared with RBKC. I confirm that I agree with the above declaration and the information on this form is complete and accurate to the best of my knowledge.

Young person's signature to agree with our Code of Conduct *

Please type full name to agree

Parent/guardian name *

Relationship *

Parent/guardian signature *

Please type full name to agree

Our Football Academy provides football coaching sessions in London for children aged 4-12 years.

Who we support

The support we provide

Where we work

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Emergency details

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Your GP

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