Leisure Cardholder Application

Leisure Cardholder Application Form
Title
First Name:
Surname
House number/name
Address:
Post Code:
E-mail Address:
Confirm E-mail Address:
Telephone (Home):
Telephone (Work):
Telephone (Mobile):
Date of Birth	dd/mm/yyyy
Male/Female:	Male Female
Where did you hear about us?	Town Crier Hunts Post Weekly News Cambridge Evening News Peterborough Evening Telegraph Website Mail shot Word of Mouth Magazine (please state below)
Do you have a disability or other long term health condition?	Physical Disability Multiple Impairment Learning Disability Health Impairment	Visual Impairment Hearing Impairment Other (please state)
To which of these ethnic groups do you consider you belong?	White 01 White British 02 Irish 03 Other White Mixed 04 White + Black Caribbean 05 White + Black African 06 White + Asian 07 Other Mixed Chinese 15 Chinese	Asian/Asian British 08 Indian 09 Pakistani 10 Bangladeshi 11 Other Asian Black/Black British 12 Caribbean 13 African 14 Other Black Other 16 Other 17 No Answer
If you think a friend would like to use this application, please use our 'send to a friend' form All personal details are held in accordance with the Council’s Data Protection Policy - Privacy Disclaimer I confirm that the above information is correct and agree to abide by the Huntingdonshire Leisure Centre regulations enforced from time to time. I agree that any information, including personal data, I provide now or in the future to the Council's Leisure Centres, may be used to manage, monitor, improve and promote the Council's services.
Please tick to confirm that you agree with the above

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