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

Please mark which training you are applying for: Please mark which training you are applying for: 6 - 11 December 2020 29 March - 3 April 2020 24 - 29 May 2020

First Name

Family Name

First Name for Name Tag

Date of Birth (dd/mm/yy)

Sex SexMaleFemale

Marital Status Marital StatusSingleMarriedSeparatedDivorcedRemarried

Place of birth

Nationality

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

Your Email

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: Have you been professionally diagnosed with:NoneDiabetesCeliac DiseaseSevere Lactose IntoleranceNut allergies

What is your involvement with member care?

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

Please describe any previous training or experience you have had in pastoral care or debriefing

What expectations does your organization have on how you will use this training?