Estia Centre Training Application Form

Question Title

* 1. Date of workshop

Date
Please enter your name as you would like it to appear on your certificate

Question Title

* 2. Your given name (first name)

Question Title

* 3. Your family name (surname).

Question Title

* 4. Your organisational details

Question Title

* 5. Are you a private (*profit-making) organisation?

Please note: there will be a £50 non-attendance charge to the organisation if participants fail to attend any training workshop without giving 24 hours prior notice.  If you are a private organisation, you will be charged £100 per day (pro rata), for our workshops.  Please use this bank transfer form to make a payment or contact estiacentre@slam.nhs.uk for more information.

Question Title

* 6. Your email address

Question Title

* 7. Your mobile telephone number (so that we can contact you during the course with any urgent information).

Question Title

* 8. Your line manager's name

Question Title

* 9. Your line manager's email address

Question Title

* 10. Please use the box below to let us know about any special requirements you have and which we will need to be aware of during this programme.

Question Title

* 11. How did you hear about this course?

Question Title

* 12. Would you like us to keep your contact details on file so that we can let you know when we are recruiting to our other courses?

Question Title

* 13. I confirm that I have checked that all the information on this form and it is correct.  I confirm that I am required to provide at least 24 hours notice of my non-attendance at any workshop and that failure to do so will incur a £50 charge. I affirm that entering my name and date and by clicking 'submit application' this will will constitute an electronic signature of this form.

On clicking 'submit application' your details will be logged on our system and we will email you one week before the course start date with further information and joining instructions.

T