Booking Form

Booking Form

Please note that Daniel's Beach House is available to:

• Children & their families going through or at the end of cancer treatment
• Families who have lost a parent or child to cancer
• Families with children with a parent going through or at the end of cancer treatment

Step 1 of 2

50%

Personal Details

Health information is treated as a special category of information under data protection legislation and we need to ask for your consent to process this data. You do not have to consent or provide the health information requested and your application will not be affected if you do not.

Child / Young Adult's Name:(Required)

D/O/B(Required)

DD slash MM slash YYYY

Gender(Required)

Ward & hospital being treated in:

Social Worker name & contact information

Essential information you feel we need to be aware of regarding the young person's needs while staying at Daniel's Beach House:

Parents / Guardians who will be staying at the property

Other family members staying at the property with ages:

Any special birthdays, celebrations or memorial days just before, during or after your stay dates?

The property has 2 steps down to the bedroom area & also out to the back courtyard. Do you require a ramp? Please give details

Email(Required)

Phone(Required)

Have you previously applied to Doing It For Daniel Foundation for a gift or short break(Required)

Yes

No

If yes, please give details

If you are a bereaved family who have lost a child or parent to cancer, please give some brief information here

Dates For Break

Please give 3 possible dates that would suit and approximate arrival time. Please note that breaks are for 5 days and begin on Fridays.

Option 1(Required)

Option 2(Required)

Option 3(Required)

Declaration

Please read & sign below:

• I certify that all information provided is accurate and true.
• I understand that inappropriate or fraudulent use of Daniel's Beach House will mean I am excluded from making any future applications to the charity.
• I understand that Doing It For Daniel Foundation accepts no responsibility or liability for loss/damage during short breaks at Daniel's Beach House.
• Use of gifts, experiences or short breaks are entirely at the applicant's own risk.

Signature(Required)

Date

DD slash MM slash YYYY