Please fill out this form with the information of all family members attending.
Please be aware that you can complete your payment using a credit card, debit card, or PayPal at the end of the form. PayPal Credit and Pay in 3 options are also available. You can reserve your spot with a £20 deposit, with the full balance due by 01/05/25.
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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Adult 1
*
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.
*
Medical condition
Additional needs
Wheelchair user
Physical, hearing or visual impairment
Mental health conditions
Behavioural conditions
Adult 1
Adult 2
Adult 3
Adult 4
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
Adult 4
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
Adult 4
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 and telephone number 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 and meals included 1st - 3rd of August 2025.
*
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.
£
169.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
£
0.00
Child 8 years + Glan Llyn Summer Break
2 nights with activities and meals included.
£
149.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
£
0.00
Child 3 - 7 years Glan Llyn Summer Break
2 nights with activities and meals included.
£
112.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
£
0.00
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
Item subtotal:
£
0.00
Deposit
Full payment must be received by 01/05/25
£
20.00
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Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Card Expiration
Security Code
Please click one of the PayPal options to complete payment and
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