*First name
*Surname
*Date of Birth
Name of carer
Gender Male Female
*Address

*Telephone number
*Mobile number
*Email address
Confirm email address
*How would you describe your disability

Learning difficulties
Physical impairment
Visual impairment
Hearing impairment
Multiple impairment
Other (please specify)

Describe any additional help you may need whilst participating
Please tell us about your medical information
Do you agree to having your name and contact details added to a mailing database for future events Yes No
How would you describe your ethnic origin
White White – British
Irish
Other white
Mixed White + Black Caribbean
White + Black African
White + Asian
Other mixed
Asian/Asian British Indian
Pakistan
Bangladesh
Other Asian
Black/Black British Caribbean
African
Other Black
Chinese Chinese
Other Other
Refused
Are you a member of any of the 5 leisure centres in Huntingdonshire Yes No
Would you like to become a member (FREE)? Yes No

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