EnergEyes

Club Application Form

* indicates required field

Name:*

Date of Birth*

Address:*

Telephone

Email:

Eye Condition

Disabilities or Health Issues

Medication

Access Needs

Transport Needs

Next of kin or contact in case of emergency*

Telephone (next of kin)

For our communication with you, what is your preferred format?*

Communication preferences (extra information)

CLUB RULES

Please read the Club Rules.

I understand the Club Rules are there to help EnergEyes and also to help keep me safe.*

Club Organiser: Aileen Milsom