Deepening Discipleship (May-July 2012) Application Form

Dear applicant

Please complete the full form. On receipt of the application form, we will contact your incumbent to confirm support of the application and to confirm details of the course accompanier. Please note that medical information is for use by the Deepening Discipleship Staff and will not be divulged to any other persons with the exception (in an emergency) of authorised medical personnel.

Name:
Address:


Post Code:
Email:
Tel:
Mobile:
Date of Birth:
Parish:
Physical or other disability / condition which might necessitate special arrangements
Medical conditions (including medicines) we need to be aware of in case of an emergency
Dietary requirements
Course Venue:
Please give a brief summary of why you’d like to participate in a Deepening Discipleship course, and what you hope to gain from it (optional)

Emergency Contact
Name:
Tel:

Incumbent:
Name:
Tel:
Email:

Name of Course Accompanier (if not incumbent):
Name:
Tel:
Email:

Please OR the form