SUSSEX COUNTY LTCJUNIOR MEMBERSHIP RENEWAL FORM2021 – 2022 Step 1 of 3 33% Name* First Surname Email Address* Please complete any of the following if changed or not previously provided, otherwise proceed to the next page.Phone NumberPhone Number (Optional)Address Address Line 1 Address Line 2 City County Post Code Date of Birth DD MM YYYY BTM NumberParent DetailsName(s), Contact(s).Special RequirementsSpecial care needs, dietary requirements, allergies or medical conditions. Payment Method*Bank TransferCardDirect Debit - AnnualDirect Debit - MonthlyChequeBank transfer to Sussex County LTC - 30-91-91 - 30880360, reference: member`s name.Please pay online when this form is submitted.Cheque payable to Sussex County LTC with member`s name on the back of the cheque.Please setup the direct debit mandate when this form is submitted, if not already done so. Three consecutive monthly instalments will be taken from your bank account at the middle of each month, starting on 15/03/21.Please setup the direct debit mandate when this form is submitted, if not already done so. One payment will shortly be taken from your bank account.Credit/Debit Card* Card Details Cardholder Name Membership Category*Junior Member aged 10 and underJunior Member aged 11 to 17Age on the 1st March 2021.Prompt Payment Discount Price: -£ 10.00 Paid before 15th March 2021.Prompt Payment Discount Price: -£ 20.00 Paid before 15th March 2021.PP Discount AmountDonation Donate Goodwill Discount Member Referral Discount CodeMember Referral DiscountApproval Required. Price: -£ 5.00 Quantity: Member Referral Name 1* First Surname Member Referral Name 2* First Surname Member Referral Name 3* First Surname Member Referral Discount AmountMonthly FeeAnnual FeeAnnual Fee £ 0.00 Signature*Date* Date Format: DD slash MM slash YYYY * I wish to renew my membership and I consent to scltc.co.uk collecting and storing my data from this form. Card and bank account data are not stored. EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.