Where Do You Use Your Max Card?

You must return this form with your Max Card application before your new card can be issued.

Please indicate the approximate number of times you have been to the following venues. Leave blank if you have not visited using your current Max Card.

SWIMMING Venue No. Venue No. Venue No. of of visits visits visitis Hebburn Central Pool Haven Point Pool TYNE AND WEAR Venue No. Venue No. Venue No. of of visits visits visitis Arbeia Roman Fort BALTIC Centre Bede’s World Arebia Roman Fort Blue Reef Aquarium Discovery Museum Down at the Farm Eldon Leisure Centre Gibside Go Ape (Matfen Hall) Gosforth Pool Hancock Museum Hatton Gallery Jarrow Hall (Bede’s Laing Art Gallery World) Centre For Life MFA Bowls Sunderland Mister Twisters Monkwearmouth Station Namco Funscape National Glass Centre Museum Metrocentre Nationwide Paintball Newcastle Castle NE Land, Sea, Air Newcastle museum Northern Stage Segedunum Roman Seven Stories Fort South Shields Museum Squiggles N Giggles Stephenson’s Railway Museum Sunderland Museum and The Customs House The Globe Gallery Winter Gardens Shipley Art Gallery Tyneside Cinema Washington F Pit Washington Old Hall Washington Wetlands West Denton Pool NORTHUMBERLAND Venue No. Venue No. Venue No. of of visits visits visitis Alnwick Castle Alnwick Gardens Bailiffgate Museum Bamburgh Castle Cherryburn George Stephenson’s Birthplace Heatherslaw Corn Mill Hexham Old Gaol Lady Waterford Hall Morpeth Chantry Bagpipe River Escapes Seaton Delaval Hall Museum Whitehouse Farm Woodhorn Museum TEES VALLEY Venue No. Venue No. Venue No. of of visits visits visitis Captain Cook Museum Cleveland Ironstone Dorman Museum Mining Museum Juvenate Health and Cleveland Ironstone Adventure Valley Leisure Club Mining Museum Guisborough Museum Kirkleatham Museum Zetland Lifeboat Museum Hartlepool Art Gallery Tweddle Farm COUNTY DURHAM Venue No. Venue No. Venue No. of of visits visits visitis Binchester Roman Fort The Bowes Museum Botanic Gardens Adventure Point Adventure Valley Beamish Museum Beamish Wild Binchester Roman Fort Botanic Garden Crook Hall and Gardens Diggerland Durham Cathedral Hall Hill Farm Darlington Railway Killhope Lead Mining Museum Museum Shildon Railway Museum Nationwide Paintball Oriental Museum The Bowes Museum Weatherriggs Animal Rescue and Conservation Centre National Venues Please list any additional venues in the UK that you have visited using your current Max Card

Child’s Name:...... DOB:......

Parent/Carer e-mail address:......

Please return this form with your Max Card application form to:

Short Break Service For Disabled Children, Level 0, South Shields Town Hall, Westoe Road, NE33 2RL. Or e-mail it to [email protected]

You must return this form with your Max Card application before your new card can be issued.