Blue Base Registration Form
Everton in the Community is a registered UK charity with the charity number 1099366.
First Name
Last Name
Date of Birth
Address
Email Address
Telephone Number
Customer Number ( from season ticket)
Details of companion (where applicable), name and contact number
Nature of disability,long-term illness or health condition
Do you use a wheelchair and/or another device to aid your mobility? (please provide details)
Do you require a parking space and if so, does this need to be accessible?(please note that due to limited parking, a space is not guaranteed with your membership)
Do you have any other specialist needs we need to be aware of?
Number of additional friends/family requested (maximum of 3)
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