Active and Able Adult Sports Club Registration Form

Active and Able Sports Club Registration Form

First Name:

Surname:

Date of Birth:

Name of carer

Gender

Male Female

Address:

Post Code:

Telephone Number:

Mobile Number:

E-mail Address:

Confirm E-mail Address:

How would you describe your child’s disability?

Learning difficulties

Physical impairment

Visual impairment

Hearing impairment

Multiple impairment

Other (please specify)

Describe any additional help they may need whilst participating:

Is there any medical information that we may need? (e.g. epilepsy, asthma, etc)

Do you agree to having your name and contact details added to a mailing database for future events? (please tick)

Yes No

How would you describe your ethnic origin?

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

Please enter the code shown on the right. This prevents automatic submissions of this form.

If you have any questions regarding the Active & Able Sports Club, please contact David Reeve on 01480 387098 or e-mail david.reeve@huntsdc.gov.uk

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