application20032004

Leigh and District Youth League

Membership Application

Season 2004 / 2005

Name of Club;_______________________

Age Group:_______________________

Secretary's Full Name:_______________________

Secretary's Address:_______________________

_______________________

Post Code: _______________________

Telephone: _______________________

Fax Number: _______________________

Mobile Number:& _______________________

E-Mail Address: _______________________

County FA Number (if Known)

______________________

Managers Name: _______________________

Mobile Number: _______________________

Managers Address: _______________________

_______________________

Post Code: _______________________

Telephone: _______________________

Fax Number: _______________________

Mobile Number: _______________________

E-Mail Address: _______________________

Manager: Do you hold any of the following? Please tick all that apply.

UEFA-A                         1st 4 Sport Level 3 Date Taken ____________
UEFA-B                         1st 4 Sport Level 2 Date Taken ____________
TEAM MANAGERS      1st 4 Sport Level 1 Date Taken ____________
Good Practice and Child Protection           Date Taken ____________

Assistant Manager&:_______________________

Mobile Number: _______________________

Managers Address: _______________________

_______________________

_ _______________________

_______________________

Post Code: _______________________

Telephone: _______________________

Fax Number:& ______________________

Mobile Number: _______________________

E-Mail Address _______________________

Assistant Manager: Do you hold any of the following? Please tick all that apply.

UEFA-A                          1st 4 Sport Level 3 Date Taken ____________
UEFA-B                          1st 4 Sport Level 2   Date Taken ____________
TEAM MANAGERS       1st 4 Sport Level 1 Date Taken ____________
Good Practice and Child Protection            Date Taken ____________

Team Colours

Home Away

Shirts:_________________________ Shirts:________________________

Shorts:_________________________ Shorts:________________________

Ground Details:_____________________________________________________________

Directions:_________________________________________________________________

Changing Facilities Yes / No

"I ____________________ ( Manager ) and I ____________________ ( Assistant Manager ) of ____________________ Football Club have been provided with a copy of Rules and Regulations of the Leigh and District Youth League and do hereby agree for and on behalf of the said team, if elected or accepted into membership, to conform to those rules and regulations and to accept, abide with and implement the decisions of the management committee of the competition, subject to the right of appeal in accordance with rule".

Signature Manager ____________________ Date ____________________

Signature Assistant Manager ________________ Date ____________________

MEMBERSHIP AND WITHDRAWAL CHARGES

Membership fee �90.00

Entrance Form with �40.00 deposit by 30th April 2004 - Cancellation by 31st May 2004 Full Refund

Cancellation by 15th June 2004 - 50% Refund of entrance fee.

Cancellation by 6th July 2004 - 25% Refund of entrance fee.

Cancellation by 31st July 2004 ? NO REFUND of entrance fee

2nd Instalment of entrance fee �30 due by 31st July 2004 with final payment due no later than 30th September 2003

Player Registration Fee �3.00 per player (Includes Personal Accident Insurance)

Does your club have Public Liability Insurance?

Please provide:-

Name of Company_________________________ Policy Number____________________________ Expiry Date:______________________________

All applications to be received before 30th April 2004 to

General Secretary

Mr. Duncan Tighe.

56, Holden Road,

Leigh,

You can apply after this date for any available spaces in our leagues.

Lancashire.

WN7 1EX

Tel: 01942 261086

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