Crisis & Trauma Response Training

Application Form - Le Rucher Only

NOTICE: Before you fill out the application form below, we want to assure you that we fully respect your privacy and will always keep your details confidential. They are never shared with a 3rd party. We use this information only to determine our ability to serve you. We will email you at the address you provide to notify you whether your application is accepted and/or to clarify any further information.

We do not use this information to make any automated decisions that might affect you. If you are accepted, your information is securely archived. Only the information you voluntarily share with us in the form below is collected.

If we are unable to accommodate your request (due to dates, etc.) your information is automatically deleted after 30 days. You have the right under EU law to request that your data be erased so feel free to contact us after your debriefing if you would like us to delete your identifying information from our records.

Next Seminar:

4-9 October 2020

Crisis & Trauma Response Training Application Form

Please acknowledge you have read the above notice and agree with it before filling in this form: Please acknowledge you have read the above notice and agree with it before filling in this form: I Agree

First Name

Family Name

First Name for Name Tag

Date of Birth (dd/mm/yy)

Sex

Marital Status

Place of birth

Nationality

Do you need a visa for France? Do you need a visa for France? Yes No

Email Address

Your full permanent postal address

Your telephone you will be traveling with

Organization for which you work

Your title/role in organization

Do you have health insurance that is valid in France? Do you have health insurance that is valid in France? yes no

I wish to be lodged at Le Rucher: I wish to be lodged at Le Rucher: yes no

Have you been professionally diagnosed with:

What is your involvement with member care?

What kinds of crisis or critical incidents have you experienced or dealt with?

Please describe any previous training or experience you have had in crisis response or debriefing:

How do you plan to use this training in the future?

12 + 4 =

Find us:

We are physically located in France, only 15 minutes from the Geneva, Switzerland airport:

2067 Route de Tutegny

01170 Cessy, France

Tel: +33(0)450.28.03.81 - Temporarily out of service (a hunter accidentally shot the line down on the road!)

Email: info@lerucher.org