You will also receive a copy by email once submitted.
All fields with * are required.
Age Group *
Under 8sUnder 10s GirlsUnder 11s BoysUnder 11s GirlsUnder 12s GirlsUnder 13sUnder 14sUnder 15sUnder 16s BoysUnder 16s Girls
Player Name *
Player Date of Birth *
FA Number (if known)
School Year 2022-2023 *
Year 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Have left school
Please indicate if you have any special medical conditions that we should be aware of e.g. Asthma
Please note: 'Parent/Guardian/Carer 1' will be the initial point of contact and also used for registration to the the MatchDay app.
Name - Parent/Guardian/Carer 1 *
Tel Number - Parent/Guardian/Carer 1 *
Email - Parent/Guardian/Carer 1 *
Date of birth - Parent/Guardian/Carer 1 *
Name - Parent/Guardian/Carer 2 *
Tel Number - Parent/Guardian/Carer 2 *
Email - Parent/Guardian/Carer 2 *
Name - Parent/Guardian/Carer 3 (if required)
Tel Number - Parent/Guardian/Carer 3 (if required)
In the event that my Son/Daughter is injured whilst playing Football, travelling to and from the football events and I cannot be contacted I give my consent for my child to receive medical treatment.
Yes, I give consentNo (Please contact coach to discuss)
I agree to be bound by and to observe the Club Rules, Code of Conduct and the Rules and Regulations of the Football Association Limited and Devon County Football Association, and all competitions in which the club participates. I also agree to paying a monthly fee of £12 pounds for membership at the start of each month and a match fee of £3 for each game played. If my son/daughter receives a booking at a game due to their behaviour then i agree to pay the fine to the club in full. I have read the Club's coronavirus risk assessment and accept the responsibilities it places on me. I consent to the above named player joining in training and matches during the pandemic.
Yes, I acceptNo (Please contact coach to discuss)
Your child may be photographed whilst playing football for Cullompton Rangers Youth Football Club and these photo's may be published on the Clubs Website/facebook/Twitter and/or printed in the local newspapers. If you do not wish your child to be photographed or for his/her picture to be published on the club website or in the local press then please select the 'no' box.
Yes, photos allowedNo photos please
Name of person who completed this form *