APPLICATION FORM

HARROGATE WEEKEND SCHOOL 2010

Please use BLOCK letters:

Surname: (Mr/Mrs/Miss/Ms/Dr)........................................................................

First Name: ................................for name badge (if different)...............................

Address: .........................................................................................................

......................................................................................................................

Post Code: .......................... Tel: ...................................

                                            e-mail : ..............................................................
(Email will be used to send all information if you have supplied your address)

I enclose cheque for:

             £140.00 full cost double / twin / triple room per person
             £160.00 full cost single room   n/a
or          £192.00 full cost for 3 nights (shared room)
             £222.00 full cost for 3 nights (single room)

or            £25.00 deposit to reserve accommodation in:

single room   twin room    double room    triple room for:
                            2 nights      3 nights

cheques payable to: RSCDS York & North Humberside Branch

I would like to share a room with......................................................................

Any special requirements..................................................................................

Signed........................................................................... Date..........................