Tea Dance Application :: Sir Simon Milton Foundation

Title Required

First name Required

Last name Required

Email address

Contact phone number Required

Postal address line 1 Required

Postal address line 2

Town/City Required

Postcode Required

Which Westminster Ward do you live in? Required

Date of birth (DD/MM/YYYY) Required

Please confirm any dietary requirements:

Please confirm any mobility requirements:

Wheelchair user

Walking frame

Other

How many times you have been to the Tea Dance?

Please click 'Yes' if you are happy to receive correspondence from the Sir Simon Milton Foundation

Yes

No

Would you like to bring a guest? Required

Yes

No

Guest's title Required

Guest's first name Required

Guest's last name Required

What is your relationship with your guest? Required

Carer

Friend

Relative

Guest's email address

Guest's contact phone number Required

Guest's postal address line 1 Required

Guest's postal address line 2

Guest's town/city Required

Guest's postcode Required

Guest's date of birth (DD/MM/YYYY) Required

Guest's dietary requirements:

Guest's mobility requirements:

Wheelchair user

Walking frame

Other

Tea Dance 2024 tickets