aura hamdden a llyfrgelloedd
leisure & libraries
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TheinformationinBox 1 is mandatoryforactifcardregistrationBox 1
DateofRegistration: Gender: Male□ Female□Title:Mr/Mrs/Miss/Ms/Other(circleasappropriate) DateofBirth:
FirstName(s): LastName:
HouseName/Number:
FirstLineofAddress:
Town: County: Postcode:
HomeTelephoneNo: MobileNo:
Email:
Thefollowinginformationisoptional:EmergencyContactName:
EmergencyContactTel.Number:
NameofGP:
MedicalConditions:
Treatment(ifany):
RegistrationForm-actif Card
IfUnder18years,Parent/GuardianFullName:
Title:Mr/Mrs/Miss/Ms/Other(circleasappropriate)
FirstName(s):
HouseName/Number:
FirstLineofAddress:
Town: County:
PostCode: Tel.Number:
The following information is optionalAsanorganisationcommittedtovaluingdiversityandpromotingequalitywemonitorparticipationrates. Thisinformationhelpsustoensureourserviceprovisionisequitable.
EthnicityChooseonesectionfromAtoFthencircletoindicateyourculturalbackground .A. WhiteBritish:-English Scottish Welsh Other(Pleasewritein) _______________________________________________________ Irish AnyotherWhitebackground(Pleasewritein) ____________________________________________________________
(pleasetick)
B. MixedWhiteandBlackCaribbean WhiteandBlackAfrican WhiteandAsianAnyotherMixedbackground(Pleasewritein) ____________________________________________________________________
(pleasetick)
C. Asian, Asian British, Asian English, Asian Scottish, Asian WelshIndian Pakistani BangladeshiAnyotherAsianBackground(Pleasewritein) ____________________________________________________________________
(pleasetick)
D. Black, Black British, Black English, Black Scottish, or Black WelshCaribbean AfricanAnyotherBlackbackground(Pleasewritein) ____________________________________________________________________
(pleasetick)
E. Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh,orotherethnicgroup.Chinese
(pleasetick)
F. Any other background (Pleasewritein) ______________________________________________________________________
(pleasetick)
Religious CategoriesBuddhist Jewish Muslim Other Christian Hindu Sikh None
MarriedorinaCivilPartnership□ NotMarriedorinaCivilPartnership□Doyouconsideryourselftohaveadisabilityorlongtermhealthcondition? Yes □ No□ThedisabilityDiscriminationAct1995definesdisabilityas:‘apersonhasadisabilityifhe/shehasaphysicalormentalimpairmentwhichhasasubstantialandlongtermadverseeffectonhis/herabilitytocarryoutnormaldaytodayactivities.
Preferred Language: (pleasestate) __________________________________________________________________________________
Data Protection ActAnypersonalinformationsuppliedbyyouwillbeheld,stored,usedand/orprocessedasandwhennecessarybyFlintshireCountyCouncilforthepurposeofcarryingoutitspublicfunction,forequalopportunitiesmonitoringandthepreventionanddetectionofcrime.Disclosureofyourpersonaldatamaytakeplaceandbegiventoexternalpartiesshouldtheyshowreasonablecausefordisclosuretobemadeandtotheextentthatthelawallows.IagreethatanyinformationordataIprovidemaybeusedandsharedwithinFlintshireCountyCouncilfortheabovepurposes.
Signed:___________________________________________________________________________Date:_______________________
Thisformisavailableindifferentformats;pleaseaskifyourequirethis.
Leisure Services may wish to contact you with information concerning the different activities it offers.
Please tick here □ if you do not wish to receive this information.
aura hamdden a llyfrgelloedd
leisure & libraries
www.aura.cymru www.aura.wales
Like Follow usHoffi Dilynwchni
