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
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Name
First Name
Last Name
Address
Street Addres Line 1
Street Address Line 2
Town
County
Postcode
Email
example@example.com
Parent/Guardian mobile number
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Adult 1 completing the form
Full Name & Age
Adult 2
Full Name & Age
Adult 3
Full Name & Age
Child 1
Full Name & Age
Child 2
Full Name & Age
Child 3
Full Name & Age
Child 4
Full Name & Age
Child 5
Full Name & Age
Please complete for each participant. Use the space in the next section to add further details.
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
Further details (please include adult or child and number)
Please complete for each participant. Use the space in the next section to add further details.
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
Further details (please include adult or child and number)
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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.
Please Select
Yes
No
I consent to Autistic Haven CIC sharing the information in this form with the Urdd Glan Llyn Centre.
Please Select
Yes
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.
Please Select
Yes
No
Only Adults
Only my children
I agree to the Urdd retaining my contact details in order to contact via e-mail with information about our events, courses and activities
Please Select
Yes
No
I agree to Autistic Haven CIC retaining my contact details in order to contact via e-mail with information about our future events.
Please Select
Yes
No
Family Payment Section
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( X )
Adult Glan Llyn Summer Break
2 nights with activities and meals included.
£
165.00
Quantity
1
2
3
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5
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10
Child 8 years + Glan Llyn Summer Break
2 nights with activities and meals included.
£
145.00
Quantity
1
2
3
4
5
6
7
8
9
10
Child 3 - 7 years Glan Llyn Summer Break
2 nights with activities and meals included.
£
106.00
Quantity
1
2
3
4
5
6
7
8
9
10
Child Under 0-3 Glan Llyn Summer Break
2 nights with activities and meals included.
£
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Choose from one of the PayPal options to
make your payment.
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