DETAILS OF LEARNER

 Name

Address

Daytime Tel No (landline)

Mobile Tel No

Email

Date of birth

Do you have any additional needs or requirements which you may need support with?

 □     Yes                       □ No

If yes, please provided details:

Are you registered disabled?

□     Yes                       □ No

If yes, provide details:

Unique Learner Number (if applicable)

DETAILS OF THE COURSE & PAYMENT

Course title

Promotional code for discount

What is your present role (if applicable)?

□     Childminder     □     Nanny           □ Au Pair

□   Other (please state)

How did you hear about the course?

Why do you wish to undertake this course?

Payment Options

 □ Option 1: Full payment

 □ Option 2: Payment by instalments 3, 6 or 9 months

 Receipt made out to :

DECLARATION

In signing this form, I confirm the following:

□ The information I have provided is correct to the best of my knowledge.

□ I have read and agree to @Home Childcare Training’s terms and conditions overleaf.

□ I have read and agree to @Home Childcare Training’s Data Protection statement overleaf.

□ I agree to pay the fees as stated.

 Signed: …………………………………………………………                 Date:_____/ _____/ ______