Apply for West Berkshire Everyone Active Discount

For discounts at leisure and sports centres.

1. Friendly Url
2. Friendly Url
4. Unique Reference Number
Discount Applied for*
1. Adult
2. Concessionary
3. Young Person
1. Concessionary - Reason
  
  In receipt of benefits
  
  Disabled
  
  Aged over 60
2. Proof of entitlement for concessions would also be required
Discount is applied to your membership via the EA website and App. Physical cards are not usually issued but can be, if you would prefer.
1. Preferred discount method
  
  Applied to Membership via the website and App
  
  Card
Contact Details
1. Name
  1. Title
  2. Other Title
  3. First Name*
  4. Last Name*
2. 1. Date of Birth*
  2. dd/mm/yyyy
3. Address
  1. Address Postcode
    
    Postcode
    
    Address
  2. Full address*
4. 1. Email
  2. Telephone / Mobile
    
    Numbers, spaces, + , ( , and ) are all valid characters
  3. Your telephone contact details may be used to contact you if a course or a class for which you have booked has to be cancelled.
5. 1. Error:Please select
    Preferred method of communication*
    
    Email
    
    Post
    
    Text
  2. Error:Invalid
    Email or Text*
  3. * You have specified Email as a preferred method of communication, but not entered your email address above
  4. * You have specified Text as a preferred method of communication, but not entered your Mobile number above
  5. * Please enter either an e-mail address or phone number to allow staff to contact you when your card is ready.
  6. Your details including your e-mail address may be used to keep you informed about programme developments, services and events.
  7. If you do not wish to receive such information please tick the box.
Additional Information about Yourself
1. Please complete these questions so that we can make sure that we are meeting the leisure time needs of all communities and individuals in the District. All of the information you give will be kept completely confidential and is only used as part of high level monitoring reports.
3. Gender
  
  Female
  
  Male
  
  Prefer not to say
4. Do you have any long-standing illness or disability?
  
  No
  
  Yes
5. ('long standing' means anything that has troubled you over a period of time or that is likely to affect you over a period of time)
6. If yes, please indicate the category that best describes your disability
7. If other, please specify
9. To which of these groups do you consider you belong?
  1. Please select
  2. Please specify
11. Terms and Conditions
  1. I agree to the Terms and Conditions*
  2. For further information, see Membership Terms and Conditions
Email Confirmation
1. I would like a copy of this submitted form emailed to me
2. Email
1. Form Reference Number
For Office Use Only
1. Centre of Issue
2. Resident Card Number: LC
3. Resident Card Number: Lib
4. Resident Card Category
5. Documents seen
6. Active From
7. Renewal Date
8. Photo Taken: YES/NO
9. Signed
1. * Please correct any of the validation issues highlighted above
  Preferred method of communication
  Error:Please select
  Email or Text
  Error:Invalid

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Apply for West Berkshire Everyone Active Discount

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