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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