Sport and leisure discount card for Luton - Active Luton

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User application form Please tick as appropriate Concessionary user Leisure card user Office use only Card no:............................................................. Issued by:........................................................... Date of issue:..................................................... Place of issue:..................................................... Personal details Surname..................................................... Title Mr/Mrs/Miss/Ms First name................................... Date of birth............................... Address.................................................................................................................. ................................................................................................................................ ...................................................................... Postcode...................................... Tel: home.............................................................................................................. Tel: work............................................................................................................... Mobile................................................................................................................... Email...................................................................................................................... ✄ To ensure that our leisure services are effective and reaching our entire community, please select one from A to E and tick the box to indicate your ethnic background A. White British Irish Any other white background B. Mixed White and Black Caribbean White and Black African White and Asian Any other mixed background (please state) C. Asian or Asian British Indian Pakistani Bangladeshi Kashmiri Any other Asian background (please state) D. Black or Black British Caribbean African Any other Black background (please state) E. Chinese or ethnic group Chinese Any other (please state)
Do you consider yourself to have a disability? Yes No If ‘yes’ please tick which of the following best describes your disability: mental physical learning sensory Terms and conditions • you must show your card at reception when claiming discounts or concessions • you must quote your card number at the time of booking to gain discounts or concessions • your card is valid for one year from date of issue. However, the pensioner card can be reissued free every year • your card will be cancelled if it is used fraudulently or if you breach the terms and conditions of use • your card is not transferable • you will be charged a fee at the current rate for a replacement card. • children under the age of 16 must have this form signed by a parent/carer. Signed................................................................................................. Date..................................................................................................... Data Protection Act 1998 The personal data you have provided will be handled in accordance with the principles of the Data Protection Act 1998, and used for the administration of your go4less leisure card. The data is shared jointly between Luton Borough Council/Active Luton and from time to time may be used to provide you with information about activities we feel will be of interest to you. If you do not wish to receive mailings, please tick this box.
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Sport and leisure discount card for Luton - Active Luton

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