| Date required | Number of children | Number of adults |
| 5th August morning | ||
| 5th August afternoon | ||
| 12th August morning | ||
| 12th August afternoon | ||
| 19th August morning | ||
| 19th August afternoon | ||
| 26th August morning | ||
| 26th August afternoon |
Name:
Group name: (e.g. name of organisation, etc)
Address:
Postcode:
E-mail address:
Contact telephone number
Deposit cheque for £15 enclosed (tick here)__________ or payment by credit card below, or I have paid by Paypal (tick here _______) (payments@canalmuseum.org.uk)
We accept Mastercard Visa Solo Switch, JCB, Maestro cards. We don't accept Diners Club or American Express. Please complete the following:
Please charge the sum of £ _______ to my Mastercard/Visa (delete as applicable) card number:
__________ ... __________ ... __________ ... __________
Start date ________/_______ Expiry date: _____/________
Name as it appears on the card. _________________________________
Security Code (last 3 digits on signature strip on the back of the card) _________
(Note: The address given above must be the one registered as the cardholder's address and must be complete with postcode.)
Signed: (Cardholder) _________________________________ Date: ____________________