23 Bridge Street

Lisburn

County Antrim

BT28 1XZ

T: / 028 9260 4422
F: / 028 9260 3874
E: /
W: /

Strengthening Families Facilitators Training Application Form

Information &

Registration Pack

Course Registration Form

* No course registration will be accepted without this required information.

*Course Title & Reference Number
Each course place must be registered for separately.
*Title (Mr/Mrs/Miss/Ms etc.)
*Name
Job Title
Organisation
*Address
*Postcode
*Contact Telephone no:s / Work: / Mobile:
E-mail Address
Please note this will be used as primary form of contact.
*Do you have any special needs in terms of dietary requirements or access which you would like us to be aware of?
*In which Health and Social Care Trust area do you primarily work (or live) in? / Belfast Health and Social Care Trust
Southern Health and Social Care Trust
Other Health and Social Care Trust
Other please specify:
*Please choose the sector which best describes the work which you do: / Health Primary Care
Health Secondary Care
Criminal Justice
Schools and Youth Services
Community and Voluntary
Social Services
Private Sector and Housing
Not Known/ Other
Where did you learn about this training?

If you are being released from work to attend this course please ensure ask your direct line manager to sign this form:

*Title (Mr/Mrs/Miss/Ms etc.)
*Name
Job Title
*Contact Telephone no:s
E-mail Address
Direct Line Manager Signature
(Please note if this form is being completed electronically, managers name in type will be taken as a signature.

In accordance with the Data Protection Act 1998, personal data processed by ASCERT for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes.

Please be aware that this courses is FREE to, however if you do not cancel a place with sufficient notice (5 days) or do not turn up without a valid reason, you will be required to pay a non-attendance fee of £30, and may not be allocated a free place on future courses.

The cancellation charge for this course will be directly sent to your line manager for payment.

Please return this form to: Training Administrator, ASCERT, 23 Bridge Street, Lisburn, County Antrim, BT28 1XZ, Fax to 028 9260 3874 or email to

Course date and Venue

  • Strengthening Families will run from 9am (registration)
  • 9.30am – 5pm
  • Lunch will be provided. Please ensure we have details of any specific dietary requirements on the registration form

COURSE / DATE / VENUE / I wish to attend this course (please tick)*
Strengthening Families Facilitator Training
(1 day) / September 10th 2015 / Haven Close (Villa 1)
St Luke’s Hospital Armagh,
  • Course places will be allocated on a first come first served basis, and places will only be allocated on receipt of a completed registration form for each participant wishing to attend. You can either send in hard copy or simply email this form back to us to register for a place on this course. This course has a maximum of 35 places so early booking is advised.
  • You will receive notification by email (unless otherwise requested) of a place on the course within one week of submitting an application form.
  • We operate a reserve list for all courses and will also let you know if you have been allocated a place, but are on the reserve list.
  • In order to be a group facilitator you must attend the full days training.
  • The course is fully funded through the Public Health Agency