COURSE BOOKING FORM

Plas y Brenin

Capel Curig

Betws-y-Coed

LL24 0ET

01690 720 214
This form should only be used to book a course and date advertised via our website www.pyb.co.uk and where online booking is not possible.

Please use one form per person per course.
COURSE BOOKING FORM
Course Details
Course Title:*
Course Start Date*

DayMonthYear
Select Course Package*
Amount of Attendees*
Mountain Training/British Cycling Registration No. (If Applicable)
Customer Details:
Lead Booker Details:*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Special Dietary Requirements*
Medical Condition, Allergies or Disabilities*
In the Unlikely Event of an Evacuation Does Anyone Within Your Booking Require Any Assistance?:*
Details of Emergency Contact *

NameTelephone Number
Attendee #2 Details:*

First NameLast Name
Attendee #2 Date of Birth*

DayMonthYear
Attendee #2 Special Dietary Requirements*
Attendee #2 Medical Condition, Allergies or Significant Disabilities*
Attendee #2 In the Unlikely Event of an Evacuation Do You Require Any Assistance?:*
Attendee #2 Details of Emergency Contact *

NameTelephone Number
Attendee #3 Details:*

First NameLast Name
Attendee #3 Date of Birth*

DayMonthYear
Attendee #3 Special Dietary Requirements*
Attendee #3 Medical Condition, Allergies or Significant Disabilities*
Attendee #3 In the Unlikely Event of an Evacuation Do You Require Any Assistance?:*
Attendee #3 Details of Emergency Contact *

NameTelephone Number
Attendee #4 Details:*

First NameLast Name
Attendee #4 Date of Birth*

DayMonthYear
Attendee #4 Special Dietary Requirements*
Attendee #4 Medical Condition, Allergies or Significant Disabilities*
Attendee #4 In the Unlikely Event of an Evacuation Do You Require Any Assistance?:*
Attendee #4 Details of Emergency Contact *

NameTelephone Number
Attendee #5 Details:*

First NameLast Name
Attendee #5 Date of Birth*

DayMonthYear
Attendee #5 Special Dietary Requirements*
Attendee #5 Medical Condition, Allergies or Significant Disabilities*
Attendee #5 In the Unlikely Event of an Evacuation Do You Require Any Assistance?:*
Attendee #5 Details of Emergency Contact *

NameTelephone Number
Attendee #6 Details:*

First NameLast Name
Attendee #6 Date of Birth*

DayMonthYear
Attendee #6 Special Dietary Requirements*
Attendee #6 Medical Condition, Allergies or Significant Disabilities*
Attendee #6 In the Unlikely Event of an Evacuation Do You Require Any Assistance?:*
Attendee #6 Details of Emergency Contact *

NameTelephone Number
Fees
The balance of your course fee is due 10 weeks before the start of your course. If a third party is paying for the course fee, please fill in the invoice details when choosing the below Payment Method Purchase Order.
The full fee of my course is
£
Please select Payment:*
Please Select Payment Method:*
PURCHASE ORDER NUMBER:*

INVOICING ADDRESS and INVOICE E-MAIL ADDRESS

CITY

POSTCODE State / Province
NOTES i.e discount codes:

State / Province
Do you have PYB Membership

No, not yetYes, I have Bronze MembershipYes, I have Silver MembershipYes, I have Gold Membership
This form should only be used to book a course and date advertised via our website www.pyb.co.uk and where online booking is not possible.
I HAVE READ AND UNDERSTOOD THE TERMS AND CONDITIONS THAT RELATE TO THIS BOOKING.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

COURSE BOOKING FORM

Course Details

Fees