<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> Active and Able Junior Sports Club Registration Form

Active and Able Junior Sports Club Registration Form

How would you describe your ethnic origin
First name
Surname
Date of Birth
Name of carer
Gender	Male Female
Address
Post Code
Telephone number
Mobile number
Email address
Confirm email address
How would you describe your child's disability	Learning difficulties Physical impairment Visual impairment Hearing impairment Multiple impairment Other (please specify)
Describe and additional help they may need while 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	Yes No
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
Other	Refused
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