Safeguarding Department Booking Form

BOOKING FORM ENGLAND NETBALL TIME TO LISTEN WORKSHOP FOR CLUB SAFEGUARDING OFFICERS When applying for an England Netball Time To Listen course please complete ALL information on this booking form: Candidate Information
Attended SCUK SPC1 Candidate Name (Ms/Mr/Miss/Mrs) Address
If you have not attended a SCUK Safeguarding & Protecting Children (SPC1) course you will not be allowed to attend Time To Listen Training.

Post Code Region CSO belongs to Your Affiliation Number / Netball ID No: Mobile No

Landline: E-mail Address

(Please provide at least one)

Emergency contact Name & No Medical Information

(e.g epilepsy, asthma, diabetes, allergies etc)

Club Affiliation Number Club Name Club Secretarys name Club Affiliation No.

I agree for England Netball to use the above details to register me as a Club Safeguarding officer. 2/-

Safeguarding Department Booking Form

(2) Time To Listen Training Course Information Jean Brown Arena, Redbridge Sports Centre, Forest Road, Venue Barkingside, Essex IG6 3HD Date of the Course Time of the Course Region Tutors Name Deposit Sunday 21st July 2013 2.00 pm to 5.00 pm London & South East Ian Moir 30.00 cheque enclosed

Payment: By Cheque only, please ensure you enclose payment. Cheques must be made payable to England Netball with the candidates name clearly printed on the back. Cheques will remain with the Course organiser which will be the Regional Co-ordinator, once the course has been attended, your cheque will be returned to the address provided on the booking form. Please Note : A Deposit of 30.00 will be requested to secure a place on the Time To Listen Course in order to secure your place. We are unable to invoice organisations for candidate payment or accept cash payments. Your cheque will be banked if you do not attend the course without a valid reason, or simply do not turn up, the onus is on the candidate to inform the course organiser, this will enable another candidate to attend. Funding: If your Club, County or another agency is funding your course attendance, please ask them to clearly state your name / candidate name on the back of the cheque and enclose course details with the cheque. Cancellation Policy: Requests to cancel a booking should be directed to your Course Organiser and will be considered on an individual basis

Safeguarding Department Booking Form

Equal Opportunities Monitoring Form

Are you male or female? Date of Birth What is your ethnic group? White White British Black or Black British Black Caribbean African Other Black Mixed White & Black Caribbean White & Black African White & Asian Other Mixed Asian or Asian British Indian Pakistani Bangladeshi Other Asian Prefer not to say Unknown

Chinese or Other Ethnic Group

Chinese

Other Ethnic Group

The Disability Discrimination Act 1995 defines a disabled person as anyone with a physical or mental impairment which has a substantial and long-term adverse effect upon his/her ability to carry out normal day to day activities. Do you consider yourself to have a disability? If Yes, what is the nature of your disability? Visual Physical Learning Other Hearing Prefer not to say Multiple

FOR OFFICAL USE ONLY:

Any further action required: Cheque received: Yes No

Date candidate confirmation letter sent: Signed off by staff member:......