- Caerphilly Leisure Lifestyle Caerphilly Leisure Lifestyle

NERS Customer Information Form

This form should be completed by Exercise Referral staff when sending customer information to the Customer Services team.

Exercise Referral staff name(Required)

Plus 2 Member ID

Please enter a number less than or equal to 999999999.

Leisure Card number

Please enter a number less than or equal to 9999999999999999.

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City Post Code

Email Address

GP subscription type(Required)

Subscription start date(Required)

Subscription end date(Required)

Reason for free-of-charge extension