D.I.A.L Great Yarmouth - Booking Form


	Booking Form

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WHEELCHAIR HIRE - Advance Booking Form
Cheque/PO to made out to D.I.A.L Great Yarmouth.
Name *
Address:*
Telephone:*
E-mail *
Address of holiday venue: *
Date of Hire - From: *	eg. 20/07/2004
Date of Hire - To: *	eg. 3/08/2004
TYPE OF WHEELCHAIR OR EQUIPMENT REQUIRED (Small wheeled chairs will need a carere to push)
Size of person - Large
Size of person -Average
Size of person - Child

Wheel Size - Large
Wheel Size - Small
Wheel Size - Commode

To be delivered
Customer to collect

Comments

Reg Charity No. 299909