Mr/Mrs/Miss/Ms_________________________________________
Address ________________________________________________
_______________________________________________________

________________________________________
County:_________________________  
Post Code:_______________

Home Tel:____________________________________
Day/Office Tel:________________________________
Fax No:______________________________________
Mobile phone:_________________________________
e-mail address:________________________________

Please tell us how you heard about Moonfleet:_________________________________________________ Occupation _____________________

First Name

Surname

DOB

Sex

Sailing Experience

Diet*

Course Required

DATES:       5/7 or 9 Days
W/Ends

FROM ________________________
1^st  _____________         2^nd____________

TO ________________________
               3^rd  ______________

CREDIT /DEBIT CARD AUTHORISATION

Please debit my VISA/MASTERCARD credit card/debit card with £ ____________                              Security Code_________

VISA/MASTERCARD

number

Expiry date ________________

Name of card holder: _____________________________________________  Visa Debit/Solo/Maestro Start Date/IssueNo______

Address of card holder:____________________________________________________________________________________

Signature of card holder: _____________________

If you want the balance of your fees, of which you will have received notification, to be automatically debited from your card, please tick the box below and repeat your signature. The debit will be made no more than 4 weeks prior to commencement of your course.

  SIGNATURE ________________________________________ Credit Cards: 2% surcharge on all Credit Card payments

THIS SECTION MUST BE COMPLETED (delete which ever is not applicable):

MEDICAL DECLARATION

Are there any medical conditions we should be aware of? (e.g. asthma, allergies, epilepsy, heart condition etc)
_______________________________________________________________________________________________________

Please detail any medication being taken
TELEPHONE NUMBER IN CASE OF EMERGENCY________________________________________________________
CONTACT PERSON IN CASE OF EMERGENCY____________________________________________________________
I confirm that the person/s booked on the course is/are in a fit condition to undertake the course and able to swim 50 metres.

SIGNATURE ___________________________________________

I/We enclose a total of £________which is a deposit of 25% or payment in full for the total course fees. Where a deposit payment has been made, I/We undertake to pay the balance 4 weeks before the start of the course. Any alterations to this booking must be made in writing.  I/We have read the conditions of booking and the schedule of payments and agree to abide by them.

NAME ____________________________________SIGNATURE ______________________________DATE ______________

Please make cheques payable to Moonfleet Sailing