Mock Student Registration Form -MCI

Mock Student Registration Form

Please fill out the form carefully for registration as a Mountaineering and Climbing Instructor Assessment Mock Student
About you
We need to collect some information about yourself and your experience so we can create the best match with an assessment candidate. This section is mandatory as it captures generic, essential details that enable us to run the course, and manage your participation, safely and securely.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

TownCounty

Post Code
E-mail
example@example.com
Mobile Number
Please confirm you are over 18

Yes I am over 18
We may ask you to be a mock student just a few days before a course start date. Are you available at short notice?

YesNo
I would like to receive email communications from Plas y Brenin National Outdoor Centre, with details about courses, events and services available

YesNo
Medical Information and Emergency Contact Details.

If you answer 'Yes' to any of following three questions, please provide details in the Additional Comments section below.
Do you have any medical conditions?

YesNo
Do you have any disabilities?

YesNo
Do you have any allergies?

YesNo
Additional Comments
For safety reasons we are required to take the details of a nominated person, whom we can contact in case of an emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you consent to your medical information being shared with candidates and assessors on the assessment course?

YesNo
Please tell us more about your qualifications and experience
Do you want to learn the skills needed for multi-pitch trad climbing?

YesNo
Previous climbing experience: (please tick all which apply to you)

Indoors at a climbing wallTop-ropeSportTrad seconding onlyTrad leadingI have never climbed before
If you have climbed before can you do any of the following?

Put on a harness correctlyTie in with a figure of 8 knotBelay a climberI cannot do any of the above
If you are lead climbing at what grade do you lead?
Please list any climbing qualifications you hold
Do you consent to your qualifications and experience being shared with candidates and assessors on the assessment courses?

YesNo
Should be Empty:

Mock Student Registration Form

About you

Please tell us more about your qualifications and experience