What is
vceard? i t c a
active active active
bookings discounts memberships
Available all year round...
Active card is Active Middlesbrough’s (Middlesbrough Council’s Sport & Leisure Services) new bookings, discount and membership card that offers you great benefits at all of the venues on the opposite page. You can choose what you want your card to be... just a bookings card or a discount card or your membership card. Or you can have your active card as all three.
active
Booking Card
This is a FREE card that allows you to book selected activities and sessions up to 7 days in advance by telephone or in person. All you need to do to get your Active Booking Card is complete sections 1 and 2 of the application form inside this leaflet.
active
Discount Card
This card gets you discounted prices on hundreds of activities at all Active Middlesbrough venues (see Active Discount Card costs on opposite page).
active
Membership Card
Now you can have your X4 Health & Fitness Club and Golf Club Membership included on your Active Card. No need to carry around lots of different cards... it can all be on your Active Card. For X4 memberships complete sections 1, 2 & 3 on the inside of this leaflet. For golf memberships complete sections 1, 2 & 4. If you are doing fitness classes or swimming lessons please complete sections 1,2 & 3.
e kiosk v i t ac Southlands Leisure Centre, Rainbow Leisure Centre and Middlesbrough Municipal Golf Centre all have a new Active Card Kiosk. This means customers with an Active Membership can fast track to their activity without having to queue at reception. This only applies to activities included on your Active Membership.
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Adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes (21/2 hours) of moderate intensity activity in bouts of 10 minutes or more - one way to approach this is to do 30 minutes on at least 5 days a week.
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(Department of Health. Physical activity guidelines for adults 19-64 years)
I verify that the information given in this application and questionnaire is complete and accurate. I understand that it is my responsibility to contact my doctor with regards to my suitability to exercise. I also understand that it is my responsibility to inform the appropriate members of Active Middlesbrough Staff of any changes to my health status. By completing this form you give Middlesbrough Council the authority to collect information about you for the purpose of Active Middlesbrough (Middlesbrough Council’s Sport & Leisure Service) on a computer database.
Where can I get an Clairville Stadium Municipal Golf Centre The Neptune Rainbow Leisure Centre Southlands Leisure Centre
active
Tel: Tel: Tel: Tel: Tel:
active ? card
01642 01642 01642 01642 01642
246767 315533 230106 592800 300428
Discount Card Prices
Which category of Active Discount Card do you require? Family Card Adult Card Young Person
£25.00 £14.00 £3.00
Student Card £4.00 Senior Citizens Card £4.00 Concession Card* £4.00
Concession rates* apply to: Senior Citizen - anyone 60 years and over Student - only full time students with a valid NUS card Carer - in receipt of carers allowance Concessionary rate also applies to anyone in receipt of the following benefits (valid form of proof must be shown at time of applying for an Active Card) • Employment & Support Allowance • Working Families Tax Credit • Disability Living Allowance • Attendance Allowance
• Carers Allowance • Job Seekers Allowance • Income Support • Housing Benefit • Council Tax Benefit
Family - applies to parents with children 17 years or under Young Person - applies to anyone up to 17 years
e v i t c a e ‘makin g more people mor
’
e v i t ac
Your • bookings • discounts • membership in one card
Active Middlesbrough would like to keep you informed of new and current Services, this may be by email, text message or letter. If you would not like this information please tick
Middlesbrough Signed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . .
moving forward
www.middlesbrough.gov.uk/activemiddlesbrough
For Active Bookings and Active Discount Card complete sections 1 & 2 only Section 1
Section 2
Surname: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mr/Mrs/Miss/Ms: . . . . . . . . . . First Name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Male
Female
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Post Code: . . . . . . . . . . . . . . . DOB: . . . . . . . . . . . . . . . . . . .
Disability/Impairment Do you consider yourself to have a disability or impairment? Visual
Physical
Mental Health
Other
Hearing
Learning
Combination
No
Tel (Home): . . . . . . . . . . . . . . . . . . . . . . . . . Tel (Mobile): . . . . . . . . . . . . . . . . . . . . . . . . . . Email: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you participate in any of the following activities? (please tick as many as you wish)
Emergency Contact Name: . . . . . . . . . . . . . . . . . . . . Tel: . . . . . . . . . . . . . . . . . . . . . . . . .
Walking - 30mins or more
Pool Fitness Classes
Fitness Classes
Bowls
In order to assess whether we are reaching all groups in our community please select which ethnic group best describes yourself.
Golf
Gardening
Jogging /Running
Racquet Sports
Swimming
Martial Arts
Team Sport
Other
White British Mixed White & Black Caribbean
Irish
Other
White & Asian
White & Black African
Other
(please state)
Cycling
How much physical activity do you do a week? Hours . . . . . . . . . . . Mins . . . . . . . . . . Asian or British Asian Indian
Pakistani
Bangladeshi
Black or Black British African
Caribbean
Other
Other
Where did you hear about Active Middlesbrough’s Active Card?
Chinese or other ethnic group Chinese
Other
Local Press
Previous Card Holder
Advertisement
Recommendation
Leisure Centre
Sure Start Publicity
Complete sections 1, 2 & 3 if joining Health & Fitness Clubs, participating in a fitness class or participating in swimming lessons Section 3
Should you answer yes to any of the following you must have verbal or written support from your doctor before taking part in physical activity with Active Middlesbrough.
Is there a history of heart disease, stroke or raised cholesterol in your family? Yes No Do you have any of the following?
To be completed by an instructor: Height: (completed by an instructor at induction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Weight: (completed by an instructor at induction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BMI: (instructor to calculate at induction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blood Pressure: (only when requested) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Heart Condition
Back Condition
High Blood Pressure
Bone/Joint Condition
Respiratory Condition
Diabetes
Waist Circumference: (only when requested) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does any of the above or any other condition prevent you from being able to exercise? Yes No If yes, please state: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Are you pregnant or recently given birth?
Yes
No
Are you currently taking any medication?
Yes
No
Does the medication affect your ability to exercise?
Yes
No
Please name any prescribed medication you are currently taking:
I am aware of my responsibilities with regards to participating in exercise classes, swimming lessons and the use of X4 Health & Fitness Clubs. I understand Active Middlesbrough’s staff cannot give me medical advice and that the purpose of this questionnaire is to inform Active Middlesbrough staff of my suitability to exercise and highlight any medical conditions prior to exercise. I also understand it is my responsibility to ensure Active Middlesbrough staff are aware of any changes to my medical status. In signing this form (on back page) it is a declaration that you are willing and physically able to participate in X4 Health & Fitness Clubs, swimming lessons and your chosen exercise class and that you have verbal or written support from your doctor if required.
Section 4
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To be completed if joining Middlesbrough Municipal Golf Centre
General Information
Membership type required:
Do you smoke? If yes please state how many: . . . . . . . . . . . . . . . . per week.
7 Day Full 7 Day Senior Citizen
Have you ever thought about giving up smoking?
Yes
No
7 Day Intermediate 7 Day Junior
5 Day Full 5 Day Senior Citizen
Debit Card
Credit Card
How much alcohol do you consume per week? Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . Have you exercised before?
Yes
No
If yes, what exercise: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Payment method:
Cash
Cheque
Name of G.P: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G.P. Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G.P. Telephone Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Membership Number: