Become a Bright Lights member

Name of Person Completing the form *

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Contact Telephone Number *

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Name of Child applying to become a Bright Lights Member *

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Child's Age and Date of Birth *

Child's Address *

Child's Diagnosis *

What School does the Child attend? *

Any special requirements or additional information Bright Lights needs to know regarding thew child *

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I agree that the data submitted in this form may be stored and processed by Brightlights. I agree to be contacted by Brightlights with regards to further information.

Bright Lights Junior Youth Club. Charity Number: 1094228.

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