Junior Membership Form First Name Last Name Date of Birth House Name, Number and Street Enter Postcode Home Tel No Mobile No Email Address Membership Category Junior (11 years and Under) Junior (12 – 18 years) WHS Handicap Index (if any) Name of current and previous Golf Clubs (if applicable) WHS Handicap Index (if applicable) CDH Number (if known) Name of member introducing you to the Club (if any) Emergency Contacts Emergency Contact 1 (Name) Relationship to Child Home Tel. No Mobile Number Work Number Email Address Emergency Contact 2 (Name) Relationship to Child Home Tel. No. Mobile Number Work Tel. No. Email Address Medical Information Doctor’s name of Child Doctor’s Surgery Address Doctor’s Surgery Tel. No. Does your child experience any conditions requiring medical treatment and/or medication? Yes No If Yes, please give details, including medication, dozes and frequency Does your child have any allergies? Yes No If Yes, please give details Does your child have any specific dietary requirements? Yes No If Yes, please give details What additional needs, if any does your child have e.g. needs help to administer planned medication, assistance with lifting or access, regular snacks? Disability Do you consider your child to have a disability? Yes No If Yes, what is the nature of the disability? Does your child have any communication needs e.g. non-English speaker / hearing impairment / sign language user / dyslexia? Yes No If Yes, please give details of any communication needs Consent from Parent / Legal Carer I confirm to the best of my knowledge that my child does not suffer from any medical condition other than those detailed above Yes No I agree to notify the Club of any changes to this information Yes No I agree to myself and my child being added to the Junior WhatsApp group Yes No I have made my child aware of the roads that they will need to cross when playing the course Yes No The attached signature will denote that my child has my permission to be on the golf club’s premises Yes No I acknowledge that the club is not responsible for providing adult supervision for my child, except for formal junior golfing coaching, matches or competition Yes No I agree to my child being transported by club representatives to and from venues when he/she is representing the club Yes No I will ensure my child reads, signs and upholds the Chesham and Ley Hill Code of Conduct for Young Golfers Yes No I agree to photos of my child being taken and used for publicity purposes Yes No By signing this document, I confirm that I have legal responsibiility for (name of child) I am entitled to give this consent, and I am aware of how the information I have provided may be used Yes No Signed (Parent or Carer) Date Signature (Junior) Date Signature (Parent/Carer) Date Submit
