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*Date of Birth
Name of carer
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*How would you describe your disability

Learning difficulties
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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
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White + Asian
Other mixed
Asian/Asian British Indian
Pakistan
Bangladesh
Other Asian
Black/Black British Caribbean
African
Other Black
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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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