Active and Able Junior Sports Club Registration Form

First Name:

Surname:

Date of Birth:

Name of parent/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?

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