Complete and return this form to: Education Department, St Christopher’s Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ. Forms can be faxed to: 020 8776 5838 or emailed to

Personal Details

First Name(s) / Surname
Date of Birth / Gender (Male/Female)
Profession / Job Title
Organisation
Address
Post Code
Home Address
Post Code / Email Address
Home Telephone / Mobile Number
Dietary Requirements
Next of Kin Emergency Contact Details
Name / Relationship to you
Phone Number / Mobile

Qualification being applied for

Course Code / Course Title / Start Date / End Date
CBTF0518 / 3 day Foundation CBT Course / 9th & 10th May 2018 / 19th June 2018

Please identify your chosen course route:

Learning and City & Guilds accreditation (on completion of written assignments) / £600
(Early Bird £480 if booked before 9th March 2018)

Or

Learning only
If you later decide you would like to undertake accreditation, you will be required to notify us and pay additional cost of £205 by 29 June 2018 / £395

Previous Qualifications

Awarding Organisation / Place of Study / Qualification Title / Level/Grade
Unique Learner Number (ULN) or Scottish Candidate Number (if known):
Fees / Please raise an invoice for the fees as follows:
Invoice To: (name and address of Fee Payer) / Total Invoice Value: / Purchase Order No. (if applicable)

Fee Payer – by signing below, you agree to pay fees listed above and confirm acceptance of terms and conditions

Fee Payer Signature / Date
Learner
I certify that the information on this form is correct, and I will inform St Christopher’s of any changes to my circumstances. I am aware that in order to practice in between dates 2 and 3 I need a clinical caseload
Learner Signature / Date

Booking conditionsThe closing date for applications is 2 days prior to the event start date. Your place is confirmed on receipt of a confirmation letter/email from St Christopher’s Education Administration. If you wish to cancel your place please refer to the cancellation policy. If a delegate cancels their place a 10% admin fee will be applied. No refunds will be given where a delegate does not attend without prior notice to Education Administration.St Christopher’s may take photographs during courses to be used for publicity and marketing purposes. Please contact a member of the Education Team if you would not like us to use your image for these purposes. This form can be photocopied for additional applications.

Data protection In accordance with the Data Protection Act 1998, we are required to inform you that your details will be retained and held on file for administrative purposes by St Christopher’s. Please be assured that we will not pass this information on to any other organisation unless we have your prior consent.

CBT Application