Become A Base Member

The Base offers a wide range of activities for young people with additional needs and their families, so why not consider becoming a member.

The Base Membership Form

Child Membership Details

Family Contact Details

Other Details

Consents

Parent/Guardian Sign Off

Child 1 Membership Details

Child 1 Forename

Child 1 Surname

Child 1 Date Of Birth

Child 1 Allergy

Child 1 Allergy Details, if yes

Add another Child?

Child 2 Membership Details

Child 2 Forename

Child 2 Surname

Child 2 Date Of Birth

Child 2 Allergy

Child 2 Allergy Details, if yes

Add another Child?

Child 3 Membership Details

Child 3 Forename

Child 3 Surname

Child 3 Date Of Birth

Child 3 Allergy

Child3 Allergy Details, if yes

Add another Child?

Child 4 Membership Details

Child 4 Forename

Child 4 Surname

Child 4 Date Of Birth

Child 4 Allergy

Child 4 Allergy Details, if yes

Family Contact Details

Address, including postcode

Main Contact Name

Main Contact Mobile Number

Main Contact Landline Number

Main Contact Email

Alternative Contact Name (if main contact cannot be reached)

Alternative Contacts' Main Contact Number

Other Details

Is there any other information that Tobin Centre needs to know in order to support your child/children's participation? (eg special education needs, disability, etc.). If yes, please give details.

The above named child/children are able to take part in activities arranged by Tobin Centre.

Responsibility for the above named child/children's safety whilst travelling to and from the Centre does not lie with Tobin Centre.

The details of the above named child/children will be held on the Tobin Centre Membership Directory for the next year.

I wish to receive information on future activities, programmes and events provided by Tobin Centre and their Partner Organisations via text, social media and email.

All photographs or video footage of the above named child/children to be used in Tobin Centre's publicity, including Tobin Centre's Facebook, Instagram, and Website Blog.

Parent/Guardian Name

Parent/Guardian Signature

Date

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Become A Base Member

The Base Membership Form

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