REGISTRATION FORM Recent Passport

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(Please use Block Letters to fill the form) Photograph

PLAYER’S DETAILS

Name :___________________________________________

Gender : Male Female Date of Birth:

Name of School and Class : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _

Primary Contact Self Father Mother Others

If other, Name :___________________________________________

Relation :___________________________________________

E-mail ID :___________________________________________

PARENT’S DETAILS
Father’s Name :___________________ Mobile No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Mother’s Name :___________________ Mobile No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E-Mail ID :________________________________________________

Address :________________________________________________

EMERGENCY CONTACT DETAILS

Father Mother Others

If other, Name :________________________________________________

Relation :________________________________________________

Jersey / Shirt Size : (as per Nike Sizing)

NIKE YOUTH SIZE

Y-S Y-M Y-L

NIKE ADULT SIZE

S M L XL
 HOW DID YOU HEAR ABOUT BARÇA ACADEMY?

Venue Promotion Promotional E-mail School Newspaper

Family / Friend Website / Facebook Other _________________

TERMS AND CONDITIONS

FITNESS

1. You must ensure that the applicant is physically fit and able to participate in the Barça Academy
Coaching activities and accordingly you accept all risks including injuries that may occur during
the Barça Academy Coaching.
2. Failure to disclose correct medical and/or physical information may exclude the Applicant from
participating in the Barça Academy Coaching.
3. Improper/wrong medical treatment being administered due to failure to disclose or provision of
incorrect medical and/or physical information shall be the liability of the person/guardian/parent
signing the form and Conscient Football shall not have any liability arising out of or in relation to
the same.
4. We may require additional information depending on the medical information supplied to us by
you before we can accept your registration.
5. In the event that the applicant needs medical attention during any Barça Academy Coaching,
you agree that we may provide and/or arrange for any appropriate and necessary treatment
at your cost.
6. Player must be of correct age at the start date of the Barça Academy Coaching.

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature of Parent: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

GENERAL

7. The safety and well-being of all applicants attending Barça Academy Coaching is our primary
concern, we therefore reserve the right to expel, without refund, any applicant who is found
bullying, behaving in a way that may be a danger to others or who is generally disruptive. If the
player is removed from Barça Academy, it is your responsibility to organize and pay for any travel,
accommodation or other expenses incurred.
8. You are responsible for arranging and paying for the applicant’s return travel to the Barça
Academy Coaching venue.
9. I explicitly give my consent to Barça Academy Bengaluru/Conscient Football the right to use my
images and videos for promotional purposed of its programs, as long as such usage don’t
amount to personal endorsement.
10. Neither you nor the applicant shall disclose or use any aspect of Barça Academy for commercial
purposes.
11. If you are not the applicant’s parent or guardian, you confirm that you have made such parent
or guardian fully aware of this registration and of these terms and conditions and they have
agreed to these terms and conditions.
12. These terms and conditions and your registration shall be governed by and interpreted in
accordance with the laws of India and shall be subject to the exclusive jurisdiction of the
Bengaluru Courts, Tribunals, Forums, quasi-judicial authorities etc. only.
13. Once enrolled at Barça Academy, I undertake that I will not represent any other academy or
club in any domestic or international tournament, with the exception of participation in my
school team and/or teams that represent the district/ state/ national football federations, in
which case I will inform my Coach/ Technical Director in advance of such participation.
14. I authorize Barça Academy to send me communication related to the Barça Academy.
 15. I authorize Barça Academy/Conscient Football to send me communication related to offers of
products and services that may be relevant/ interesting to me.
Yes No

16. I agree that Barça Academy reserve the right to cancel my registration at any time without giving
any reason whatsoever.
17. I undertake to follow all internal guidelines as outlined in the Barça Academy Handbook.

REGISTRATION POLICY

18. No refund can be given for cancellation received for Barça Academy fee.
19. The registration is non-transferable.
20. All Barça Academy coaching, activities, venues and other arrangements are subject to change
according to weather, venue availability, a satisfactory level of applicants or other factors
beyond our control. As such, we may cancel or change any Barça Academy Coaching, should
this be necessary for these reasons.
21. Submission of Registration Form does not guarantee a place in the Barça Academy Coaching
of the applicant. The decision of the Barça Academy will be final in this respect. If registration
form of the applicant is not accepted or the applicant is not admitted to the Barça Academy
Coaching, only fee upto the extent received will be refunded within 15 days of start of the Barça
Academy Coaching. Apart from this, Barça Academy/ Conscient Football will have no other
liability.
22. No refund is permitted for applicant’s failure to attend the Barça Academy Coaching.
23. By the act of filling out this registration form and making the first payment, I hereby confirm that I
am registering my son/ daughter for a minimum period of one year and will make all necessary
payment for participating in Barça Academy.

Date: _____________________________ Signature of Parent/Guardian:_______________________

LIABILITY

24. We do not accept responsibility for any death, personal injury or loss of or damage to property
other than to the extent that it results from our gross negligence or willful misconduct. You are
responsible for arranging and paying for travel to Barça Academy Coaching venue and vice
versa.
25. The cost of any damage caused by you or any applicant you have booked on the Barça
Academy to any property or facilities will be passed on to you.
26. Notwithstanding anything contained herein or otherwise, Barça Academy/ Conscient
Football’s liability shall never exceed more than the amount paid as fee to it irrespective of any
reason whatsoever.

ARBITRATION

1. Any dispute and/or difference arising out of or in relation to the present form shall be referred to
a mutually agreed arbitrator for adjudication. The proceedings shall be governed by the
Arbitration and Conciliation Act, 1996. The venue of arbitration shall be Bengaluru. The cost of
arbitration including Arbitrator’s few be shared equally between the parties.

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature of Parent: _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _

PAYMENT DETAILS
Mode of Payment : Cheque : Cash : DD : NEFT :

Date : Amount :

Name of bank : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Branch: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

____

PRIVACY CONSENT
By submitting this form, you expressly consent that Barça Academy/Conscient Football which is operating Barça
Academy may share your personal information (a) to provide products and services you request, (b) for consumer
profiling and market research.

Please note that registrations are subject to realization of payments.

 MEDICAL FORM
Applicant’s Name : _____________________________________________________________ Age:
________

Year / Class: ___________________________ Date of Birth :___________________ Gender :________________

Address: _________________________________________________________________________________________

Physician’s Name: _______________________________________________ Contact No. :

___________________

My Child has had the following: (Please tick). Medical condition and background Allergies :

Allergy Name Severe Anaphylasxis Sight/ Non-Life Threatening None

Allergen
Foods
Insects
Drugs
Animals
Grasses, Pollen
Other

Describe what happens during a reaction:

_________________________________________________________________________________________________

In the event of a reaction, what actions are necessary?

_________________________________________________________________________________________________

Has hospitalization occurred because of a reaction; No Yes Date

_________________________________________________________________________________________________

Name of allergy and medication

_________________________________________________________________________________________________

ASTHMA:
Does your child suffer from asthma? Yes No

If ‘yes’, please indicate how severe your child’s asthma is:

MILD MODERATE SEVERE

Attacks are rare, limited mostly Occasional attacks which can Attacks are regular, severe
to tightness and wheezing. be self-managed using and have required
prescribed medication.

When was your child’s last asthma attack? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _

____

Did your child require medical / hospital treatment? Yes _ _ _ _ _ _ _ _ No _ _ _ _ _ _ _ _

Please list the triggers of your child’s asthma attacks:

Does your child have any other medical problem that may require Emergency Care?

Currently taking long-term medication? Yes No

If Yes, please give additional information

_________________________________________________________________________________________________

Had your child had a tetanus injection within the last 5 years: Yes No

I have completed this medical form accurately, truthfully and to the best of my knowledge as
of today’s date. I understand that it is my responsibility to inform Barça Academy of any new
medical condition or change in this information.

Signature of Parent / Guardian __________________________ Date__________________________

Name of Parent / Guardian_____________________________________________________________

Name of Applicant ___________________________Relationship to Applicant _________________

CONSENT

I give my full consent for my child, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _to participate in Barça Academy.

I confirm that I have notified Barça Academy of any medical difficulties that could affect my child’s
ability to participate fully in these activities. I understand that some activities may be strenuous and
that a reasonable standard of fitness for them is essential. I assume full responsibility for any claims,
losses, costs, articles or liabilities arising out of or related to my child’s participation in the Barça
Academy Coaching. In cases of medical emergency, I hereby delegate Barça Academy/Conscient
Footballs’ staff the power to authorize and obtain any necessary diagnosis and treatment for my child
and I will bear all costs of the same.
 I accept that coaching activities carry with them some degree of risk both to person and
property and knowing this risk, I still desire my child to participate in the Barça Academy Coaching
program, unless I have specified otherwise in writing. In the unlikely event of an accident, I release,
waive an hold harmless Barça Academy/Conscient Football, its sisters concern, coaches, technical
staff and directors, other co-partner from any claims, losses, damages or expenses which may arise
during the camp programme. I also agree with the rules and code of conduct for players, parents and
coordinator.
With this document I authorize FC Barcelona to use my personal data shared with this
registration form to manage and communicate information about Barça Academy, as well as send
information about products, services and/or FC Barcelona or companies linked with the club
promotions, that can be of your interest.
I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, the parent/guardian of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ have read and approve the above and agree to all terms and conditions.

Signature of Parent / Guardian _____________________________________________________________ Date ______________________

Name of Parent / Guardian ____________________________________________________________________________________________

TRANSFER OF IMAGE RIGHTS FOR MINORS

BARÇA ACADEMY – BENGALURU

[.....................................................], of legal age, date of birth [.../..../......], National ID number

[...............................], with address at [...............................................................................], telephone no.
[.......................................................] and email address [...................................................]; with the
signature of this document, acting on behalf of the minor [......................................], with National ID
number [.........], given his/her status as parents (Father/Mother)/legal guardian thereof (“Minor”); and

[.....................................................], of legal age, date of birth [.../..../......], National ID number

[...............................], with address at [...............................................................................], telephone no.
[.......................................................] and email address [...................................................]; with the
signature of this document, acting on behalf of the Minor given his/her status as parents
(Father/Mother)/legal guardian thereof (“Minor”),

NOTICE: This document needs to be signed by those people who hold the parental custody of the Minor. In the event of one
sole person holding such condition, the document may be signed by such single person. In the event the undersigned has
been authorized on behalf the owner of the parental custody, he/she may sign indicating “with authorization” besides the
signature, not being the FCB responsible if such authorization has not been granted.

With the signature of this document,

DECLARES

1. That I authorize the participation of the Minor in the activities organized by the Futbol Club
Barcelona School ("FCB"), related to playing football, including playing tournaments or
others, (the "Activities").

2. That I have been duly informed by FCB that during the Activities of the School, both inside
and outside its facilities, FCB itself or third parties with its authorization will be able to record,
file, make photographic, audiovisual and/or sound recordings.
3. That I hereby accept and authorize FCB to record the image of the Minor (including image,
voice and name), through any audio, photographic and/or audiovisual medium, while they
are attending, participating in and/or watching the Activities of the School.

4. That I give my voluntary consent and therefore expressly authorize FCB to use it for its own
purposes or through transfers to third parties, around the world and for an indefinite period,
all or part of the contents recorded or captured during the Activities of the School, including,
among others, any tournaments, in which the image, name and/or voice of the Minor
appears, either individually or collectively, for advertising, promotional and informative
purposes of FCB and, in particular, of the School and its activities, including, among others,
and in a non-limiting way, dissemination through the Internet (website, social networks and
others), television, public display and communication in its own exhibitions spaces and
museums or those of third parties, in its own written media or that of third parties etc., as well
as for the promotion of third-party activities.

5. By way of example, and not limited to, I authorize FCB to disseminate and publicly
communicate the images obtained during the School’s Activities referred to here in which
the Minor may appear, and transfer them to third parties, through any medium, whether in
physical and/or digital format, as well as their public use, reproduction, dissemination and
communication and, in general, for any activity through any medium or channel (offline and
online, including, among other things, websites, social networks, etc.), be they owned by FCB
or third parties for the purposes set forth in point 3 above.

6. I accept that this authorization is free of charge, so I agree not to claim any remuneration,
payment, fee and/or compensation in the future.

7. That I acknowledge and accept that, in the event that any third party, to which FCB has
delivered the contents referred to herein in which the image of the Minor appears for its
public dissemination and/or communication, violates the terms of this authorization, it will be
liable for any type of compensation, sanctions and expenses arising from possible claims that
may be made by the signee for negligence and/or misuse, which may violate the integrity,
dignity, honour and image of the Minor. Therefore, I hold FCB harmless from any liability for all
purposes for any type of use made by a third party external to FCB, that is contrary to or
different from the terms set forth in this document.

8. That I acknowledge and accept that the media, files, content and advertising and
promotional assets here referred to in which the image of the Minor may appear are and will
be owned by FCB.

9. That I authorize the incorporation of the aforementioned data to an automated file for
which the responsible party is FCB, domiciled at Av. Aristides Maillol, s/n, 08028 Barcelona,
which is to be considered confidential, and therefore, will be used and processed in
accordance with current regulations on personal data protection, in order to manage the
transferred rights, and send information about the activity of the School and the
corresponding tournaments. Likewise, I am hereby informed that I can exercise the rights of
access, rectification, opposition, cancellation, limitation and portability of the processing of
the minor's data by FCB by sending an e-mail to lopd@fcbarcelona.cat. I authorize FCB to
keep the Minor’s data during their relationship with the School and if I have not
communicated my desire for FCB to stop doing so. FCB has informed me of my right to claim
before the competent controlling authority.

[] By checking this box, I authorize FC BARCELONA to incorporate the Minor’s data into the
Barça Fans programme and send commercial information that it considers relevant, such as
promotions, competitions, news, events, etc.

All this with the sole exception of those uses or applications that could violate the right of
honor in the terms provided in Organic Law 1/82, of 5 March on Civil Protection of the Right
of Honor, Personal and Family privacy and Self-Image.

For all the above, I sign freely, consciously and voluntarily this transfer of the Minor’s image
rights document, accordingly, for all purposes and without reservation

In Barcelona, on __________________________2019

SIGNED

_______________________________________
Legal representatives/tutors/parents of the Minor

______________________________________
Minor
 INSTRUCTIONS FOR COMPLETING THE REGISTRATION

1. Please fill the form in Block Letters.

2. Registration form should be signed by parents only.

3. The printed and signed form including medical and consent form, along with the
Cheque/DD/Pay order of requisite amount drawn in favor of “Conscient Football”

Ecumenical Christian Centre, Post Box. No. 11,

Whitefield, Bangalore – 560066, Karnataka, India.

Sahakara Nagar : +91 9148846111

Whitefield : +91 8095402345
Koramangala : +91 9148284505
Begur : +91 9008231181

(Please notify at barcaacademy.bengaluru@conscientfootball.com once the payment is made)

4. One copy of the applicant’s proof of birth and 2 photographs must accompany this form.

5. Receipt will be issued, upon request.