If you wish to book a place for you son/daughter please complete the form below.
Your request will be dependent upon an assessment of your son/daughters needs and we will contact you upon receipt of this form to arrange an appointment.

You can send us the form in two ways:

1) Complete the form on screen & simply print the page and send it to us, Or
2) Click the "Send form by email" button - that's it!

Person making booking:

Title First Name Last Name

Booking made for:

Title First Name Last Name

Contact details:

House Name or Number
Street or Road Name
Town
County
Postcode
Home Telephone
Mobile Telephone
Email address

Probable days required:

Monday Tuesday Wednesday Thursday Friday

I wish to use the Myriad Centre from:

Month Year

I am not sure when but:

I may use the Myriad Centre in the future ? (please tick)

We are investigating the possibility of opening during weekends and evenings. If you are interested in using Myriad during this time please complete the following:

I would be interested in using Myriad at weekends:

for one day ? for two days ?

I would be interested in using Myriad for:

evenings.