Garry1st41stAid Training

Course Booking Form

 

 

Course Details:

 

 

Course:      __________________________________

 

Dates:        __________________________________

 

Location:   __________________________________

 

Delegate Details:

 

Name: ___________________________________________________________________________

Home Address: ___________________________________________________________________

__________________________________________________________________________________

County:       ________________________________________________Post Code: _____________

Telephone: _______________________________________________________________________

E-mail:       _______________________________________________________________________

 

Company Details if Necessary:

Name of Contact: _________________________________________________________________

Company Name: __________________________________________________________________

Address:  _____ ___________________________________________________________________

__________________________________________________________________________________

County:     ______________________________________________Post Code: ________________

Work Tel: _________________________________________________________________________

E-mail:     _________________________________________________________________________

 

Previous First Aid Training:

Details of Course:   _____________________________________________________

Dates of Course:      _________________________________________________________________

 

 

 

 

 

Equal Opportunities policy:

If there is anything that may affect your learning that you feel I should know about please provide details below:

________________________________________________________________________________

 

If you have a medical condition that we should be aware of (i.e. diabetes, epilepsy etc.) please provide details below:

________________________________________________________________________________

 

Date of Birth (dd/mm/yyyy):   ______/______/________

 

Ethnic Origin (please tick):

Asian British                       Black African                      Chinese.                              White British

Asian other                         Black British                        Indian                                  White European

Bangladeshi                        Black Caribbean                 Pakistani                             White Other

                                             Black Other                                                                    White Ethnic

 

 

Delegate payment details Amount payable:  £ ________________

 

Please complete if you the delegate are paying:

 

Contact Name:   ________________________________________________

Address:   _____________________________________________________

_______________________________________________________________

County:   _______________________________ Post Code______________

I wish to pay by cheque: Deposit 20%              £____________________

                                                 Full amount        £____________________

 

Cheque Number:     ___________________________________

 

Cheques should be made Payable to: Mr G M Seabrook

 

Company Paying:

Contact Name:   _____________________________________________

Company Name:    ___________________________________________

Billing Address:      ___________________________________________

_____________________________________________________________

County _______________________________   Post Code____________

E-mail________________________________Telephone_____________

 

 

I agree to abide by the terms and conditions. I can confirm that I have the appropriate knowledge of the subject of the course that I am attending

 

Signed__________________________Name____________________________Date____________