Leek Town Juniors

First Name *

Last Name *

Email *

Phone *

Alternate Contact Name *

We would contact this person in the event of being unable to reach yourself.

Alternate Contact Phone *

Safety PIN *

Please enter a 6 digit numerical PIN / memorable word. We’ll use this incase you need someone else to collect your child from us. We will not be able to release your child to anyone other than yourself if they can not quote the children’s PIN / memorable word - For this reason your child PIN / memorable word should be secure and not an obvious date or sequence of numbers.

Marketing *

Keep me updated with details of more experiences with Leek Town that may be relevant to me

Yes

No

Password *

Confirm Password *

Parent Details