Chelsea FC Foundation Kicks Registration Form

Premier League Kicks, funded by the Premier League through the Premier League Charitable Fund, uses the power of football and sport to inspire young people to reach their potential.

Through our free sports provisions to 8-18 year olds in South West London we aim to:

Promote participation in sport in areas of high need
Inspire and support young people to progress into positive pathways, building supportive relationships with one another and the authorities
Promote integration and champion equality, diversity and inclusion

By completing this registration form, you confirm that you: consent to us collecting, processing and storing your special category data, that you have provided. Collection of this special category data is for health and safety purposes, as well as reporting on our Charitable impact.

Which Kicks venue are you registering for?*

Phoenix Youth Club - Which Session are you registering for?

Cobham FC - Which Session are you registering for?

Tudor Rose - Which Session are you registering for?

Westway - Which Session are you registering for?

Churchill Gardens - Which Session are you registering for?

Worlds End Estate - Which Session are you registering for?

Alton Estate - Which Session are you registering for?

Furzedown - Which Session are you registering for?

Pimlico - Which Session are you registering for?

St Bede's School - Which Session are you registering for?

Elays Youth Club - Which Session are you registering for?

Kingsmeadow - Which Session are you registering for?

St Luke's - Which Session are you registering for?

Eel Brook Common - Which Session are you registering for?

Ashburton - Which Session are you registering for?

South Thames College - Which Session are you registering for?

Young Person's Full Name*

First NameLast Name

Young Person's Date of Birth*

Date

Young Person's School Name

Young Person's Address*

Street Address

Street Address Line 2

City

Postcode

Young Person's Identifying Gender*

Identifying Gender: Other

Young Person's Ethnicity*

Ethnicity: Other

Does the young person consider themselves to have a disability?*

YesNo

Disability: If yes, please provide details

Does the young person have any of the following medical conditions?

If you ticked any of the above medical conditions, please provide details

Does the young person carry an Adrenaline Auto-Injector (AAI)?*

YesNo

Is the player undergoing any medical treatment at present?*

YesNo

Medical Treatment: If yes, please provide details

Does the player take any medication?*

YesNo

Medication: If yes, please provide details

Has the young person suffered any broken bones or had any serious injury or surgery in the past 12 months?*

YesNo

Injury: If yes, please provide details

Is there any additional information that we should be aware of in order to provide the best care possible?

Chelsea FC Foundation Kicks Registration Form

Young Person's Information

Medical Information

Parent / Guardian Contact Details

Walking Home Alone Consent

Consent