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Title: Mr Mrs Ms Miss Dr

First name: *

Surname: *

Phone number: *

Email address:

Address: *

Address line 2:

Town/City: *

County/Region: *

Country: *

Postcode: *

I am a member of the MS Society:

Your connection to MS:

I have MS:

A friend has MS:

Family member:

Carer:

Other MS connection:

I use a wheelchair:

I use mobility aids:

Your date of birth: DD/MM/YYYY

I have additional requirements:

How will you be travelling to the venue? Car Coach Train Plane

Do you require a disability parking space? Yes No

I would like to attend the Research Presentations on:

Saturday:    Sunday:

I would like to attend the inclusive club night:

Number of Club Night tickets:

I am interested in becoming a volunteer for MS Life:

Where did you hear about MS Life?

MS website:

MS mailing:

MS Matters:

External website:

Local branch:

Friend/Family:

Past attendee:

Other:

Wheel & Walk

I would like to participate in Wheel & Walk:

Yes:    No:

Number of under 16 tickets: (£5 per ticket):

Number of adult tickets: (£10 per ticket):

Wheel & Walk T-shirt size(s) (one per participant):

Small: Medium: Large: Extra-Large:

Next of kin name:

Next of kin relationship:

Next of kin contact phone number:

Please can my fundraising go towards my local branch:

Name of branch:

My Style Fashion Show

I would like to buy tickets for the My Style Fashion Show:

Yes:    No:

Number of Fashion Show tickets required (£10 per ticket):

Payment Options (clear)

Credit card:

You will be contacted by phone for your card details

Invoice:

Invoice will be sent to the address provided above unless you select this box , and you will be contacted for your alternate details

Cheque:

All cheques are payable to: MS Life, c/o Benchmark Communications, 14 Blandford Square, NE1 4HZ

Upon retrieval of your payment you will receive a booking confirmation and your tickets.