Junior Membership Renewal Form

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Name*
First Surname
Email Address*
Please complete any of the following if changed or not previously provided, otherwise proceed to the next page.
Phone Number
Phone Number (Optional)
Address
Address Line 1 Address Line 2 City County Post Code
Date of Birth

DD
MM
YYYY
BTM Number
Parent Details
Name(s), Contact(s).
Special Requirements
Special care needs, dietary requirements, allergies or medical conditions.

Payment Method*
- Bank Transfer
- Card
- Direct Debit - Annual
- Direct Debit - Monthly
- Cheque
Bank 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 monthly instalments will be taken from your bank account at the beginning of each month, starting on 02/03/20.
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 under
- Junior Member aged 11 to 17
Age on the 1st March 2020.
Member Referral Discount Code
Member Referral Discount
Approval 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 Amount
Monthly Fee
Annual Fee
Annual 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.
Name
This field is for validation purposes and should be left unchanged.