Cornwall Rugby Football Union

Name

Address

Email address

Telephone

(Please detail phone and mobile)

Course Applied For

(please tick)

Safeguarding & Protecting Young People

         X

Club Welfare Officers Course

Date of Course

28^th March 2011

Venue of Course

Saltash RFC

Which Rugby Club are you a member of?

What is your role at the club?

Do you hold a current RFU-processed, Enhanced Criminal Records Bureau (CRB) check?

CRB Number

(if known)

Please advise us as to your occupation?

Gender

Male

Female

Date of Birth

       /        /

Do you consider yourself disabled

Yes

No

If Yes, please indicate the nature of your disability

Visual

Physical

Multiple

Hearing

Learning

Other

Prefer not to say

If Yes, do have any specific requirements in relation to your attendance at the workshop?

If you are applying for the Club Welfare Officer Course you must have attended safeguarding /child protection awareness training (since January 2005).

Please indicate (tick relevant box) the course you have attended:

ssUK Good Practice and Child Protection or Safeguarding and Protecting Children in Sport

Date Attended:

Venue:

Tutor:

RFU Safeguarding and Protecting Young People in Rugby

Date Attended:

Venue:

Tutor:

Other and/or Statutory Agency training

Please provide detail:

Date Attended:

Venue:

Tutor:

Course Payment Detail

All delegates attending the Safeguarding & Protecting Young People course must pay in advance of attending the course - please enclose a cheque for £15 payable to ‘Rugby Football Development Ltd’ and send it with this form to the address below.

All forms and payment MUST be received at least 14 days prior to the course.

All Club Welfare Officers attending the Club Welfare Officers Workshop do so FREE OF CHARGE.

I agree to the Rugby Football Union (RFU) retaining personal data which I have supplied insofar as is necessary for the purpose of administration of the course/s.

I agree that the RFU can provide my name, rugby club and role within rugby to the tutor prior to the course.

Applicant’s signature

Date

Please return this form to –         Mr Alexis Holding,

                                                Equity & Safeguarding Administrator

                                                Community Rugby Department,

                                                Rugby Football Union,

                                                Rugby House, Rugby Road,

                                                Twickenham, TW1 1DS

                                                Tel:  020 8831 7987                Fax: 020 8831 7442

                                                E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Official Use Only:

Date completed

Comments

Participant info put onto course database

Participant sent confirmation email

Participant sent joining instructions

(two weeks prior to course)