Integrated Training Programme: Risk-Taking and Young People

Training Course Booking Form

If you are completing this form electronically, please complete all grey areas, you will need to save form first and then email to .

Course Title:Please select from the drop down listAlcohol Brief InterventionsHealthy ConversationsHow to Evaluate Physical Activity & Healthy EatingLet’s Get Moving: Implementing the Physical ActiviMotivational Interviewing - Level 1: An IntroductiMotivational Interviewing - Level 2: Developing yoPlanning for Healthy Eating & Physical Activity PrSmoking Cessation - Very Brief Advice (VBA)Smoking Cessation - NCSCT Level 1 & Face to Face SSocial Marketing: Reaching Communities
Course Date(s):
Course Date(s) (2nd Choice):
Title: Mr MrsMsDr Name:______
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We aim to make our training inclusive for everyone, please let us know of any individual needs or requirements:
Reasons for wanting to attend this course:
Course Participant:
I agree that I will attend the training days and undertake all other training requirements as detailed in the course outline. I understand that any late attendance or failure to attend without providing a minimum or 5 working days notice (subject to circumstances), that a fee of £50 for a full day, £25 for up to a half day may be incurred.
Please print name & title:
Signed: Date:
MANAGERS ENDORSEMENT: (THIS SECTION MUST BE COMPLETED)
I agree to support this application and understand the terms and conditions laid out in the course outline. I understand that in the event of late attendance or this person failing to attend the course without sufficient notice that a fee may be incurred.
Please print name & title:
Email address: Direct Tel No:
Signed: Date:
Please note booking forms without line manager signature will not be processed
Please return your completed form to:
Health Promotion Services Training Department
Mail Point HPS, Level A
RoyalSouthHantsHospital
Brintons Terrace
Southampton
SO14 0YG
Tel: 023 80713342
Fax: 023 8071 3351
Email:

Please complete the Diversity and Equality monitoring form overleaf

DIVERSITY AND EQUALITY MONITORING FORM

We are committed to valuing diversity and promoting equality. We will use this monitoring form to ensure equality of access to training.

This information is provided in confidence and held securely in line with the Data Protection Act. Information related to ethnicity will be made anonymous before being used to evaluate the commitment to valuing diversity and promoting equality.

Please tick the boxes or fill in information as appropriate.

ETHNIC ORIGIN
(Census 2001 Ethnicity Categories)
White – British / Black or Black British – Caribbean
White – Irish / Black or Black British – African
Other White background / Other Black background
Mixed – White and Black Caribbean / Chinese
Mixed – White and Black African
Mixed – White and Asian / Other Ethnic background
Other Mixed background
Information declined
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Bangladeshi
Other Asian background
DISABILITY
I have a disability / 
I am registered disabled / 
I do not have a disability / 
AGE
16 – 21 years
22 – 30 years
31 – 40 years
41 – 50 years
51 – 60 years / 
60 + years

THANK YOU FOR COMPLETING THIS FORM