Student Application Form

Note: For those of you using a screen reader it will be best for you to do a quick read through before filling the form in

If you need any help filling in the form please phone Isabell on 07731 867931

Note: Only hit the return/enter key when you are ready to send the form.

Fields with a * must be filled in

Which courses do you wish to apply for

Your details:

First name*

Surname *

First line of address

second line of address

City-Town

Post code

Your preferred Telephone: number *

Second telephone number if any

E-mail Address *

Date of birth

Other details we need to know

Which format do you prefer to have information in? (if available)

Guide dog owners

Yes I will be bringing my guide dog

If yes to above please bring everything your dog requires

Hearing aid wearers

I would like to use a induction loop-radio if available
I do not use a induction loop system

Health and Mobility Issues

Yes I do have health or mobility issue(s)

If the answer is yes & you believe that it will be helpful for us to know about these issues please give details otherwise leave blank

Guides requirements

Do you wish us to arrange a guide

I would like you to arrange a guide
No I don’t need you to arrange a guide

If no: Your guides details- Full name

first line of address

Second line of address

City-Town

Post code

Their preferred telephone: number

Second telephone number if any

E-mail Address

If yes what is your preference for?

Do you have any dietary requirements?

If other please state

In case of an emergency

Please give a contact telephone number of someone to be contacted in an emergency

Emergency contact details: Full name *

Relationship to you *

Their preferred telephone: number *

Second telephone number if any

Deposit or full payment

I will be paying a deposit or full amount by

by letter post
BACS
letter post
BACS


Please send a non-returnable deposit of £50 per course (or the whole fee) to:

Add-venture in Learning
c/o Isobel Phillips
2 Holly Drive
Pen-y-ffordd
CHESTER
CH4 0NE.

Please note: The balance is due 6 weeks before the course begins

Cheques to be made payable to Add-Venture In Learning.
BACS payments to: Lloyds, 30-00-01, A/c 02904643.
Payee reference [surname + course title]. Please also advise Isobell if paying by BACS.

Email: phillipsisobell@yahoo.ie, Telephone 07731 867931

Note: Contact details will be held on file for the purpose of mailing of newsletters and course information only.