Strathcarron Hospice
APPLICATION FORM
Surname_____________________________________________________
First Names _________________________Mr/Mrs/Ms/Other___________
Address______________________________________________________
_____________________________________________________________
__________________________________Post Code___________________
Tel.No.(Work)________________________ Home_____________________
Email address:__________________________________________________
Qualifications___________________________________________________
Present Post____________________________________________________
Place
of Work __________________________________________________
****************************************************
COURSE APPLIED FOR: ___________________________________________
______________________________________________________________
Date/s ______________________________________Fee_______________
Payment ‹ I
enclose a cheque made payable to Strathcarron Hospice
‹
Please send invoice to ______________________________________
_________________________________________________
Special Dietary Requirements _____________________________________
Signature __________________________________ Date _______________
Please complete and return with payment to: Deanne Francis, Education Secretary, Strathcarron
Hospice, Randolph Hill, Denny, FK6 5HJ
Tel: 01324 826222
Fax: 01324
824576 Email: deanna.francis@strathcarronhospice.org
On receipt of application form an acknowledgement and
confirmation of place will be sent.
Application Forms may be copied.
PLEASE SEE CANCELLATION POLICY – SEPARATE SHEET