Please fill out this form with the information of all family members attending. Please note payment section can be found at the end of the form.
We would like to assure you that the information you provide to Autistic Haven CIC is handled securely and with the upmost 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 (Adult 1 completing the form)
*
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 2
Full Name & Age
Adult 3
Full Name & Age
Adult 4
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.
Rows
Medical condition
Additional needs
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)
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Doctors Name, Surgery & Telephone number
Emmergency contact not attending the camping trip.
Name & Telephone number
Will you be bringing a Tent, caravan, camper or motorhome?
*
Tent
Caravan
Campervan/motorhome
Not sure yet
If bringing a tent please choose it's width.
1-2 m
2-3
>3m
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.
Would you prefer to camp in the designated area for early sleepers?
Please Select
Yes
No
NB. Noise should be kept to a minimum after 10:30 PM
I consent to 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 Autistic Haven CIC website or any other social media platforms.
*
Please Select
Yes
No
Only Adults
Only my children
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
My Products
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1 pitch for 3 nights at Tyntandderwen Campsite
Nights of July 29, 30th & 31st
Free
£
Free
Quantity
1
2
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5
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9
10
Item subtotal:
£0.00
£
0.00
Electric for 3 nights
6 hookups available.
Free
£
Free
Quantity
1
2
3
4
5
6
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8
9
10
Debit or Credit Card
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Last Name
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