Your name and contact details | |
First Name* | Surname* |
Address* | |
Postcode* | Country (if not UK) |
Email Address | |
Telephone number | Mobile |
I would like the following to be given out to other participants via a contact list after the event has finished:![]() ![]() ![]() ![]() ![]() ![]() |
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Some useful information for us | |
I have been to an ECC event before* ![]() ![]() |
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If yes, where and when was the last one? | |
I heard about ECC from![]() ![]() ![]() ![]() ![]() ![]() ![]() |
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Travel to the event | |
I plan to travel to the event by
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I would like a lift if possible: ![]() ![]() |
I can offer a lift: ![]() ![]() If so, for how many people? |
Event information | |
I may be interested in facilitating a base group ![]() ![]() |
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I may be interesting in organising the following workshops: | |
I have the following particular needs (rather than preferences): | |
I would be interested in buddying a first time attendee. ![]() ![]() |
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Emergency Contact Please nominate someone we can contact in case of emergency* | |
Their name* | Their relationship to you |
Their contact phone number* | Will they also be on the event? ![]() ![]() |
Payment Concessionary rate £250.00, Low income £500.00, Average income £590.00, High income £670.00 | |
The total amount I will pay for the event is* £ ![]() ![]() which is a minimum 25% of the total amount Please make cheques payable to Edward Carpenter Community Ltd (full words please) |
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Booking conditions Please tick to indicate you accept all the terms, and sign and date the form* | |
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Signed* | Date* |
Add any other comments |