Young Engineers & Science Clubs : Registration Form

This form will submit your details to us via a text email.

If you prefer, you can email jane.martin@scdi.org.uk directly with your details or contact us by telephone or post.

	Club Leader

	Title:
	First Name:
	Surname:
	Position:
	Telephone:
	Email:

	Club Details

	Name of Club:
	Name of School:
	Address:
	Postcode:

	School Telephone:

	Website:

	When do you intend to run the club?

	Day:

	Time:

	Number of club members:

	Male:
	Female:

	Please list contacts with local companies:



	Please indicate any specific assistance you require for the club: