Sign up and Pay

Activity Sign-up and Credit / Debit Card Payments

Please complete this form to sign up for activities and to make payment, where required.

Participant*

Participant Date of Birth*

Participant Postcode*

Location (where you would normally attend)* Adur Chichester Horsham

Confirmation Email address*

Choose the item or event (use the location where the event is being hosted)*

Contact details for the duration of the activity

Contact Name*

Relationship to participant*

Contact Email*

Contact Phone No*

Alternative contact no*

GP, Surgery and medical information

* over 18s can certify in their own right

NHS number*

GP name and Surgery address*

GP/Surgery Phone number*

Details of any medical condition from which I / my child suffers or any additional information of which you would like the leaders on the trip to be aware. Please also give details of any medication you/your child should take and the dosage/frequency.

Please repeat any medical information you have already provided for other activities. Please also note any conditions/treatments that have been notified earlier and discontinued.

Medical conditions - type None if none (2000 chars left)*

Additional information (2000 chars left)*

You may pay your DofE Registration costs in many ways:

• We use Paypal as our credit/debit card handler
• We would prefer you use credit/debit cards in order to keep our transaction costs down, and give you an email receipt.
• Use the "Pay Now" at the bottom of the page to pay by credit/debit card.

Alternatively, you may pay by other means:

• By Bank Transfer, to Sort Code: 09-01-29 Account No: 06806956
Please use the Location (ADU, CHI, HOR), the level (G- Gold, S-Silver, B-Bronze), and Participant surname as the reference,
e.g. HOR-S-SMITH
• By cheque, payable to "OPEN D OF E IN WEST SUSSEX (No. 1169592)". Please put the same reference
on the back of the cheque.
• Please indicate how you expect to pay at the bottom of the page.

Some financial assistance may be available. Please email the Treasurer in confidence for more details.
In case of any queries or difficulty, please contact us at one of the locations as below:

Adur (Shoreham)		adur@opendofe.org
Chichester		chichester@opendofe.org
Horsham		horsham@opendofe.org

Please continue below to pay for Registration or Activities

Pay online or pay by BACS, Cheque or cash* Pay now by Paypal, if required Signup now and pay later, if required

Paypal commission

I agree to donate Paypal commission charges

Total payment due

Anticipated Payment Method* BACS Cheque Cash Free

hidAdmin

Parent or Carer First Name*

Parent or Carer Last Name*

I agree*

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