West Bletchley Free Swim Application NB:- You will be required to pay the sum of £2 annually for issue/renewal of your membership card for the FREE SWIMMING sessions, and be responsible for replacement of lost membership cards.

Which category are you applying for: Further Education [ ]

Under 16 [ ] Over 60+ [ ] Disabled [ ] Unemployed [ ]

Title: Mr/Mrs/Ms/Miss/Dr/Other: ..……………………………………………………………………………..

Forename: ………………………………………….. Surname: …………………………………………………..

Address: ………………………………………………………………………………………………………………………..

……………………………………………………………… Postcode: …………………………………………………...

Telephone number: ………………………………………………………………………………………………………..

Email address: …………………………………………………………………………………………………………....

InspireAll are committed to protecting your privacy and will send you relevant information and offers. We do not share the information you give us with any other party.

[ ] Please tick this box if you would prefer not to receive any information or offers.

[ ] I am happy to be contacted by InspireAll by email and email newsletters

I would describe my ethnic origin as:

A) White (British) [ ] B) White other (please specify) [ ] C) Black Caribbean [ ] D) Black African [ ] E) Black other (please specify) [ ] F) Bangladeshi [ ] G) Chinese [ ] H) Indian [ ] J) Pakistani [ ]

K) Other (please specify) ……………………………………………………………………………………………

* Date of Birth: ………/………/………

Signature: ……………………………………………………………………………… (under 16’s must have form signed by a parent or guardian)

This Free Swimming initiative is being funded by West Bletchley Council and will be reviewed every 6 months by the Parish Council.

Please provide proof of eligibility with your application as specified overleaf

For office use: ID seen: …………………… Signed: …………………………………. Date: …………………………... InspireAll manages these facilities in partnership with Milton Keynes Council. InspireAll is a registered charity. Charity Number 1093653

April 2019

BLETCHLEY West Bletchley LEISURE CENTRE FreeFree SwimSwim EligibilityApplication Information

All categories require proof of address, the following documents are all accepted.

[ ] School Letter [ ] NHS Card/Letter [ ] Medical Appointment Letter [ ] Child Trust Fund Letter [ ] Child Savings Account Letter [ ] Council Tax Statement [ ] Utility Bill (within last 3 months) [ ] Bank Statement [ ] Driving License

For Child cards please note that the document must clearly state the Child’s name and address and not that of the parent.

Proof of Age Under 16/16-18 years/Over 60+

[ ] Birth Certificate [ ] Driving License (photo card) [ ] Passport [ ] Card bearing the PASS Hologram [ ] School Letter [ ] Pension Book

Proof of Entitlement

Disabled

[ ] Disability Living Allowance Letter [ ] Blue Badge Pass/Letter [ ] Incapacity Benefit Letter [ ] Severe Disablement Allowance

Unemployed

[ ] Employment Service Letter (within last 3 months) [ ] Job Seekers Allowance Letter (within last 3 months)

Further Education

[ ] School/College Letter/Card [ ] NUS/OU Student Card

InspireAll manages these facilities in partnership with Milton Keynes Council. InspireAll is a registered charity. Charity Number 1093653

April 2019