Applicant details.

Name : ..............................................................................................................................................

Address : ..........................................................................................................................................

.........................................................................Post Code......................................

Telephone...............................................................................Mobile........................................

E-mail.......................................................................................................................................

In your own words please briefly describe your experience of working within the vocation of complementary therapies

In your own words please briefly describe your interest/experience in working within drug and alcohol treatment services

If in paid/voluntary work, is your employer/placement supportive of you undertaking this course?  Yes      No

Academic Qualifications including complementary therapy qualifications
Date	Course Title	Examining Body

Cirrus 9 is committed to ensuring that people with disabilities are treated fairly. All reasonable adjustments to provision will be made to ensure that disabled students are not disadvantaged to accessing this learning opportunity. Would you like to talk to the course co-ordinator about your support needs?  Yes      No Please indicate below if you have any special requirements that you would like support with.

Employer funding course    Yes    No	Invoice required

Employers Details

Organisation ..............................................................................................................................................

Address : ..........................................................................................................................................

.........................................................................Post Code......................................

Telephone..........................................................Contact Person........................................

E-mail.......................................................................................................................................

Payment for Healthy Highs is required in advance and is acceptable by Cheque/Postal Order. I enclose payment for workshops codes (        ) (        ) (        ) for the amount of £…………………… Please make payment payable to Cirrus 9 Complete the application form and send together with your remittance to Cirrus 9 c/o 24 Abbey Road Newstead Village Nottingham NG15 0BL

For office use only
Date R'cd	Date confirmation sent
Workshop code(s)
Date(s)
Certificates Issued