Up & Active Self Referral

Interested in the Up & Active Scheme?

Please fill in your details on the self referral form, and a member of our team will be in contact wiht you shortly.

    Your First Name (required)

    Your Surname (required)

    Your Address (required)

    Your Post Code(required)

    Your Email (required)

    Your Telephone (required)

    Your Date of Birth(required)

    Please select the criteria most appropriate to you:(required)

    Your Medical Conditions

    Your GP's Name

    Your GP Medical Practice

    By completing this form I agree to the terms and conditions of use at Roefield Leisure and understand that the centre may contact me via email, SMS, telephone or post for the purpose of delivering the services to me. The information collected on this form (including but not limited to my personal data) will be used by Roefield Leisure and third parties approved by Roefield Leisure to enable the delivery of services.

    Please tick the box if you would like to receive information on Roefield Leisure events, activities and promotions.

    By ticking this box I agree that Roefield Leisure and third parties approved by Roefield Leisure and acting on its behalf may contact me via email, SMS or post, using the personal data I have provided on this form, with information on events, activities and promotions.

    If you wish to unsubscribe from future email communication regarding Roefield Leisure events, activities and promotions please send an email to sport@roefield.co.uk and add unsubscribe to the subject line.