Application Form

Full Name:

Date of Birth:

Are you: Male Female
Telephone Number :
Mobile Number:
Name of your adult contact:
Other telephone number if necessary:

Your relationship to contact:-
Father Carer Relative(Please say)

How can we contact you?
Tel. Mob. Email Letter Other (Please say)

Things we need to know about you. Please tell us about any of the following:
Sight / Eye problems
Walking Problems
Medical Problems
Reading difficulties
Writing difficulties

Please tell us in the space below if there are other things about you we need to know that will help us to help you

All enquiries are dealt with in strictest confidence.

After we receive your application form, we will contact you to arrange a date for you to visit the club. When you come into the club, we will give you a Consent Form for you to take home. Please return the Consent Form as quickly as possible.