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Step 1 - Your Details

Title*

First Name*

Surname*

Telephone Number*

Email Address*

Postcode*

House Number and Street*

Address Line 2

Town / City*

County*

Step 2 - Please enter further information

Child 1 name*

Child 1 age

Child 2 name

Child 2 age

Requested timeslot

Please let us know if you have any special requirements

Name of cardholder

How did you hear about this event?

Step 3 - How we communicate with you

As a valued supporter we really want to keep you posted about news and events across St Gemma’s and to share how your support benefits local patients and their families.

We will contact you for administrative purposes regarding this interaction. We will usually send you information by post; if you would also like to receive email updates please let us know. If you wish to change how we send you information or choose not to hear from us at all, there are a variety of ways you can do this. Ring us on 0113 218 5555, email supportercare@st-gemma.co.uk or update your preferences online at www.st-gemma.co.uk/mydata.

For further information on how we use and store your details please visit www.st-gemma.co.uk/privacy. We will never sell your personal information.

I am happy to be contacted by email in the future

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