Membership-No

							Application Form for Free Swimming
60 year olds and over Title Prof / Dr / Mr / Mrs / Miss / Ms First name Surname Male  Female  Date of birth please tick  Address Postcode Tel no (home) Email address 1. Are you a current centre member? (please circle)

Mobile no Start date Yes  No 

If yes, what type of membership do you have? _________________________ 2. Do you currently swim at: West Park Leisure Centre Yes  No 

Victoria Park Leisure Centre Yes  No  If yes, how many times a week do you swim? ___________________________ 3. Do you take part in any other exercise, physical activity or sport? Yes  No  If yes, please tell us what?

___________________________________________________________ 4. Including swimming and all your other activities, how many times, on average, do you take part in 30 minutes of physical activity a week? None  Once a week  Twice a week  Three times a week  Four  Five times or times a more a week week Yes  No  

5. Do you consider yourself to be a disabled person?

6. What is your ethnic origin? Asian Black

please tick  Dual heritage  White and black Caribbean  White and black African White and Asian Other dual heritage     White

Asian British Pakistani

 Black British  African

Chinese or other ethnic group  Chinese

British   

 Any other ethnic group,  Caribbean  please Indian state: Bangladeshi  --------------Other Asian 

Irish

Other

7. How did you hear about the Free Swimming scheme? Please tick all that apply.       Poster display, where? Advert, where? Leaflet, from where? Website, which one? Local group, which one? Other, please tell us how?    Local radio Newspaper article Family or friend told me

If you would like to receive information about other Culture and Leisure activities, please tick here  All information provided will be treated in confidence and in accordance with the Data Protection Act 1998. It will only be used to provide you with information about Culture and Leisure Services. Please sign below to confirm that you have read the terms and conditions for Free Swimming and have received your information pack. Signature ___________________________ Date ______________________

For office use only:

West Park Leisure Centre 

Victoria Park Leisure Centre 

Proof of age shown  What?_____________________ Membership number ____________________ Card and information pack issued  Staff initials ___________________________