PREMIER LEAGUE

PREMIER LEAGUE
PARENTS’ CONSENT FORM (Rule S.23)
PART 1 – to be completed by the Club
Club name Football Club
Description of activity
Date(s) Time(s) Place(s)
PART 2 – to be completed by the Parent(s)
I/We [full name(s)]
of [address]
[post code]
the Parent(s) of [child’s full name] hereby consent to him/her
taking part in the activity described above and consent pursuant to Schedule 2 and Schedule 3 of the Data
Protection Act 1998 to The Football Association Premier League Limited holding and processing any and all
“personal data” and “sensitive personal data” relating to the aforementioned child contained within this Form 22
for the purpose of discharging its functions as a regulatory and governing body of football. I/We agree to bring
him/her to and collect him/her from the activity. He/she understands that it is important, for safety reasons, to
obey any instructions given by the staff in charge of the activity.
I/We agree to [child’s first name] having emergency dental, medical or
surgical treatment (including anaesthetic and blood transfusion) as considered necessary by the medical
authorities present. Set out below are the further particulars requested.
Child’s Particulars
Date of birth NHS number
Name, address and telephone number of doctor
Date of last tetanus injection
Details of any medical treatment he/she is receiving
Details of any medicine he/she is taking
Details of any diet requirements or other special needs
My/our Particulars
Work address(es)
Work telephone number(s)
Home telephone number/Mobile(s)
Alternative contact person [name]
[address]
[telephone number(s)]
Signed
Date 20
Form 22
249
PREMIER LEAGUE FORMS