Glan Llyn Outdoor Activity Centre Payment & Registration form

Please fill out this form with the information of all family members attending. Please note that you can make your payment through PayPal at the end of the form.

We would like to assure you that the information you provide to Autistic Haven CIC and shared with the Urdd Glan Llyn Centre will be treated with utmost confidentiality. Our organisations hold a strong commitment to maintaining the privacy of our clients and partners, and we will take all necessary measures to ensure that your data is handled securely and with the utmost respect.
If you encounter any problems filling in the form please contact Janatha on 0771 615 328 or email autistichaven@gmail.com

Name

First NameLast Name
Address

Street Addres Line 1

Street Address Line 2

TownCounty

Postcode
Email
example@example.com
Parent/Guardian mobile number

Adult 1
Date of last Tentanus Injection. Details of any medical treatment at Present
Adult 2
Date of last Tentanus Injection. Details of any medical treatment at Present
Adult 3
Date of last Tentanus Injection. Details of any medical treatment at Present
Child 1
Date of last Tentanus Injection. Details of any medical treatment at Present
Child 2
Date of last Tentanus Injection. Details of any medical treatment at Present
Child 3
Date of last Tentanus Injection. Details of any medical treatment at Present
Child 4
Date of last Tentanus Injection. Details of any medical treatment at Present
Child 5
Date of last Tentanus Injection. Details of any medical treatment at Present
Doctors Name, Surgery & Telephone number
Emmergency contact not attending Glan Llyn
Name & Telephone number
Please use this section to to include sensory issues or triggers, preferred communication methods, any activities or environments your child particularly enjoys or ones we should avoid, and anything else you would like us to know to make your holiday easier and more enjoyable.
Any queries prior to the event.
I consent to the individuals named in this form as participants taking part in an event organised by Autistic Haven CIC at the Urdd Glan Llyn Centre which involves a 2 night stay with organised outdoor activities 5-7th of August 2024.
I consent to Autistic Haven CIC sharing the information in this form with the Urdd Glan Llyn Centre.
I consent to the Urdd or Autistic Haven CIC taking photos and/or video footage of the participants named in this form during activities and consent to them using any photos or footage on the Urdd or Autistic Haven CIC website or any other socaial media platforms.
I agree to the Urdd retaining my contact details in order to contact via e-mail with information about our events, courses and activities
I agree to Autistic Haven CIC retaining my contact details in order to contact via e-mail with information about our future events.
Family Payment Section*
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Adult Glan Llyn Summer Break2 nights with activities and meals included.
£165.00 Quantity



Child 8 years + Glan Llyn Summer Break2 nights with activities and meals included.
£145.00 Quantity



Child 3 - 7 years Glan Llyn Summer Break2 nights with activities and meals included.
£106.00 Quantity



Child Under 0-3 Glan Llyn Summer Break2 nights with activities and meals included.
£ Free Quantity



Total

£0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

	Medical condition	Additional needs	Wheelchair user	Physical, hearing or visual impairment	Mental health conditions	Behavioural conditions
Adult 1
Adult 2
Adult 3
Child 1
Child 2
Child 3
Child 4
Child 5

	Allergies/intolerances	Dietary requirments	Confident swimmer	Non Confident swimmer
Adult 1
Adult 2
Adult 3
Child 1
Child 2
Child 3
Child 4
Child 5

Please fill out this form with the information of all family members attending. Please note that you can make your payment through PayPal at the end of the form.

If you encounter any problems filling in the form please contact Janatha on 0771 615 328 or email autistichaven@gmail.com