Fred Perry Table Tennis Urban Cup 2011 – National Finals

Date: 3rd DecemberVenue: London Business Design Centre, Islington, London

Parental Consent Form

Please complete both sides of this form in BLOCK CAPITALS and return it to your PL4S Co-ordinator.

Local Event Organiser Name:Contact Tel:Email:

Failure to do so could result in your child being unable to part.

First Name

Surname Sex:M/F

Date of Birth Age:

Child’s Home Address Post Code:

Home Telephone Number

Email Mobile:

Disabled Yes/no - If yes, please give details

School School Year:

Medical/Special needs

(please give details of allergies, injuries, health problems etc)

Name of next of kinRelationship to childAddress (if different from child’s)Contact telephone numbers

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Declaration of Parents/Carers

a. I agree to my son/daughter/ward taking part in the Fred Perry Urban Cup Table Tennis competition 2011, having read and understood the information supplied by the Local Event Organiser

b. I consent to any emergency medical treatment necessary during the competition itself. I therefore authorise the supervisor to sign any written form of consent required by hospital authorities on my behalf, should the delay required to obtain my signature be considered likely to endanger my child’s health, by the said authority. In such circumstances, I understand that every effort shall be made to contact me prior to this action being taken.

c. I will ensure that any changes in circumstances which will affect my child’s participation in the Event will be notified to the Local Event Organiser as soon as possible prior to the Event.

Signature of Parent/Carer: Date:

Consent for Photographs/Film Footage

Photographs and film footage maybe taken at the Fred Perry Urban Cup table tennis competition.

The photographs and film footage maybe be used by the English Table Tennis Association, Fred Perry or Premier League 4 sport for publicity material such as press releases, TV and media, newsletters, promotional displays and promotional video.

a. I hereby grant Fred Perry Urban Cup table tennis Event Organiser the absolute right to use images resulting from photography of the Fred Perry urban Cup. This includes any reproductions or adaptations of the images for all general publicity purposes.

Signature of Participant: Date:

Signature of Parent/Carer: Date:

Data Protection Act 1998 – The information you have provided will be held for the purposes of registration for the Fred Perry Urban Cup 2011 and will be disclosed to the Competition Organisers and ETTA Sports Development Officers.

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