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Comments

This field is for validation purposes and should be left unchanged.

Instructions

Complete and sign the form below
Once you have completed the form, notify the reception desk and they will take you to your fixer!

Your Name*

First Last

Date of Repair*

Which repair café are you visiting today?*

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Venue Email Notification

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Associate User With Location

Your Postcode

Your Email Address*

I don’t have an email address

I don’t have an email address

Your Telephone Number

I don’t have a telephone number

I don’t have a telephone number

Your Address*

Street Address City County Post Code Country

Description of your item’s defect / problem*

Please describe your item’s problem, for example:
How did it break?
What isn’t working?
What do you think may be wrong with it?

Data protection privacy notice*

Repair Cafe Wales respects your privacy. Any personal information you supply us with will be kept secure and processed in line with the Data Protection Act 2018. For full information on how Repair Cafe Wales handles your data, please see our full Privacy Policy here. Alternatively, please ask a host at your repair café reception desk to view the policy.

I agree to the Privacy Policy

Data protection privacy notice continued*

Repair cafés are public events and filming/photography may take place for Repair Cafe Wales’ marketing and publicity uses; online; or in any third-party publication. Are you happy to be included in this activity?

Yes
No (please advise a repair café host)

Marketing notice*

Repair Cafe Wales would occasionally like to contact you to let you know about exciting news or events that we think you might be interested in. Please indicate if you’re happy for us to contact you.

Yes
No

Consent*

Please review your repair café House Rules here.

I confirm that I have read, understood and agree to the House Rules of Repair Cafe Wales.

Signature*

Organiser Consent

For organisers only.

In my role as a repair café organiser, I am completing this form retrospectively for the visitor. I confirm that the details provided herein are an exact match to the details provided by the visitor on a paper repair form, which I have retained and includes a wet signature from the visitor that owns the item(s). I will provide Repair Cafe Wales with an electronic copy of the paper repair form within one month of today’s date.