Sensory/Fidget Bag Order Form

Payment Info

Payment can be made by bank transfer to

Sort Code – 831515
Acc no – 00292135

Or in cash at West of Scotland Autism & Asperger’s Centre.

Name

Address

Email Address

Phone Number

Receiver name

Receiver age

Receiver gender Receiver gender Male Female

Bag Colour

Picture/Design on Bag

Text on Bag (name/saying etc

Preference (select below) Preference (select below) Ear Defenders Ear Plugs

Payment Method Payment Method Cash Card Bank Transfer

Confirm Order Confirm Order Confirm Order

6 + 12 =