Clontarf Hockey Club Junior Payment Registration Form Date Membership Details Club Section * Youth Girls Youth Boys Were you a member of Clontarf Hockey Club in 2020/21 season * Yes No Have you already registered a Youth Member? Please only click 'Yes' if this is the second child you are paying for. There is a second child discount however, this does not apply for the first child. * Yes No What was the name of the previous registered Youth Member(s) * Membership Type * Youth (Playing Youth & Adult Hockey) €125.00 Youth (Only Playing Youth Hockey) €125.00 If you have already registered a Youth Member you qualify for our additional Youth Member discount. Please select below the Youth Membership Type * Youth (Playing Youth & Adult Hockey) €100.00 Youth (Only Playing Youth Hockey) €100.00 Total Membership Fee SECTION A.1 YOUTH PLAYER INFORMATION Child's First Name * Child's Surname * Child's Date of Birth * Education * Primary School Secondary School Child's Gender * Male Female Child's Class * Junior Infants Senior Infants 1st Class 2nd Class 3rd Class 4th Class 5th Class 6th Class Child's Class * Junior Infants Senior Infants Child's Year * 1st Year 2nd Year 3rd Year 4th Year 5th Year Child's Year * 1st Year 2nd Year 3rd Year 4th Year 5th Year 6th Year Parent/Guardians Full Name * Parent/Guardians Phone Number * Mobile or Landline Parent/Guardians Email * Parent/Guardian Relationship To Child * 2nd Parent/Guardians Full Name (If required) 2nd Parent/Guardians Phone Number ((If required) Mobile or Landline 2nd Parent/Guardians Email (If required) 2nd Parent/Guardian Relationship To Child (If required) SECTION B. OTHER Medical Disclosure (Allergies, Epilepsy, Diabetes, Heart Conditions, Special Needs etc) Would you be interested in your child attending a Midterm/Summer Camp? Yes No Would you be interested in taking an umpiring course? Yes No Would you be interetsed in taking a coaching course? Yes No How would you like to help? Please confirm the following I agree to photographs and/or videos being taken and the use of photographic and video material by Clontarf Hockey Club Please subscribe me to our club's newsletter & fixtures/results updates Declaration * I consent to having this website store my submitted information so Clontarf Hockey Club Committee can respond to my inquiry. I have read and agree to the Members Data Privacy Policy Total Membership Fee Amount Due Payment - Debit/Credit Card * Members Data Privacy Policy If you are human, leave this field blank. Submit
