Speech & Language Registration Form

Speech & Language Registration Form

Please complete to enrol your child. Thank you
Child's name

First NameLast Name
Parents name

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Post Code
Birth Date:

MonthDayYear
Privacy Statement: We will store this form securely at our premises and the information will be entered onto a computer database. Access to the information will only be given to staff. This information will be used to enrol your child on our monthly speech & language group sessions. Your information will not be transferred or given to any other person/s without your express permission. If you want your details removing from our database and files immediately, please contact us on 01274 561308/office@downsyndromebradford.co.uk
Cost is £6 per month/£24 for the term. This fee is classed as a donation as we do not wish to exclude any family from this service.

If you would like to enrol your child please sign below.

If you would like to donate towards the sessions please follow the links below.

thank you
Gift Aid: If you (or your partner) is a UK taxpayer please let us know if we can Gift Aid any donations today or in the future. See details below.

Yes, I am a UK taxpayerYes, my partner is a UK taxpayerNo thank you as I am not a UK taxpayer
If your partner is a UK taxpayer, please state their full name
Signature

Clear
Once you submit your application, we will contact you shortly to complete your membership application. Thank you!
My donation for the group sessions

prevnext( X )
GBPsuggested amount, thank you

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: