TERRIBLE TUDORS HALF TERM WORKSHOP
PLEASE REGISTER YOUR INTEREST BY COMPLETING THIS FORM. THIS ACTIVITY IS SUITABLE FOR 5 YRS UPWARDS. IN THE ADDITIONAL COMMENTS BOX BELOW ADD ANY SIBLINGS (NAMES/AGES) WHO WOULD LIKE TO PARTICIPATE. DATES, TIMINGS AND MORE INFORMATION WILL BE CONFIRMED FOLLOWING REGISTRATION.
Patient Information
Full Name
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
Female
Male
Patient condition(s)
Is your child currently receiving hospital treatment?
Yes
No
If yes, please indicate which hospital below
Evelina
GOSH
St Mary's Hospital
The Royal London
UCLH
RNOH
The Royal Marsden
Noah's Ark
The Royal Brompton
St George's
Kings College
University Hospital, Southampton
The Whittington Hospital
Nottingham Children's Hospital
Other
Choose which hospital
Parent Information
Name
First Name
Last Name
Phone Number
-
Prefix
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Device Name
This is the name that appears on your screen when joining a Zoom session.
Additional Comments
Please verify that you are human
*
SUBMIT
Should be Empty: