SELF-REFERRAL FORM

Interested in the LET’S LIVE LIFE Scheme?

Please fill in your details below and a member of our team will be in contact.

The LET’S LIVE LIFE scheme is a borough wide project that will be tailored to your needs, and will give you access to either of the following:
  • 6 weeks use of the gym, varied classes & social groups, tailored programme, 1-1 support, full app access, priced at £25.
  • 4 weeks free trial access to the app for On Demand classes, to follow from home. 

    Your Full Name (required)

    Your Address (required)

    Your Post Code (required)

    Your Email

    Your Telephone (required)

    Your Date of Birth (required)

    Please select the criteria most appropriate to you (required)

    Other

    Have you suffered from Covid/Long Covid? (required)

    Have you been adversely affected by the Covid pandemic? IE anxiety/loneliness/depression/sedentary lifestyle (required)

    By completing this form I agree to the terms and conditions of use at Roefield Leisure & Longridge Gym and understand that the centres 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, Longridge Gym and third parties approved by Roefield Leisure & Longridge Gym 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, Longridge Gym 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.