Active Card Application

Centre
Select a centre...Bradley Stoke Active Lifestyle CentreBradley Stoke LibraryCadbury Heath LibraryDownend LibraryEmersons Green LibraryFilton LibraryHanham LibraryKingswood Active Lifestyle CentreKingswood LibraryLongwell Green Active Lifestyle CentrePatchway LibraryStaple Hill LibraryThornbury Active Lifestyle CentreThornbury LibraryWinterbourne LibraryYate Active Lifestyle CentreYate Library

Title*

First Name*

Surname*

Age*

Date of Birth*

Email

Mobile

Telephone

Address

Postcode

friend/familybannerword of mouthwebleafletemailsocial mediatextnewspaper

To help us understand the needs of all people, please select your ethnicity from the list supplied:
Please selectAfricanAny other Asian backgroundAny other Black/African/Caribbean backgroundAny other ethnic backgroundAny other Mixed/Multiple Ethnic backgroundAny other WhiteArabBangladeshiCaribbeanChineseDeclinedGypsy or Irish TravellerIndianMixed White & AsianMixed White & Black AfricanMixed White & Black CaribbeanNot ApplicablePakistaniUnknownWhite BritishWhite Irish

Do you consider yourself to have a disabiltity?YesNoDecline

If applicant is under 16, print parent/guardian name

I do not wish my child to use the internet in the libraries

We will contact you to administer and deliver services relevant to your membership such as information about bookings and reserved items. Please let us know how you would like to be contacted below.

Please contact me by*EmailMobilePost

We would like to contact you with other information and services that are relevant to your membership of the Active Partnership. Are you happy for us to provide this information?YesNo