APPLICATION FORM Active Birth Professional Training

Your Full Name *

Your name as you would like it to appear on your attendance certificate (if different to the above)

Date Of Birth *

Email *

example@example.com

Home Telephone Number *

Mobile Phone Number *

Address *

Street Address

Street Address Line 2

City

Postal / Zip Code Country

Do you have any children? If yes, please tell us how old they are.

Course you're applying for (title & starting date) *

What is your current activity and/or involvement with pregnancy and birth?

What would you like to get from this course?

How do you plan to use the knowledge you gain from this course in your life/work?

Please upload a recent photo of yourself.

This will be used simply to identify you when you sign in for the course. The photo will be filed with your application form and kept strictly confidential, as per our data security statement below.

You can also email your photo to jb@activebirthcentre.com

Click here to upload...

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Signature *

Clear

Date *

Date

YOUR DATA SECURITY

Data security is very important to us. Information provided will only be used to contact you regarding this course, and you can opt out at any time. Yur details will be kept safe and will only be availabl to Janet and her professional training partners. It will never be passed on to a third party.

CANCELLATION AND REFUND POLICY

Once booked, your place is reserved for you and is non-refundable except inexceptional extenuating circumstancessuch as a bereavement, serious illness or admission to hospital. In such an event please inform us as soon as you can. A deferment to the next course may be agreed. The final date for submitting requests for a deferment or a refund for the above reasons is on or before the first day of the course.