ECB COACH EDUCATION APPLICATION FORM 2009/10

Name: ……………………..................…………. Date of Birth: ………….............…… Age: ……………

Address: …………………………………………………………………………………....................................…………

………………………………………………......................…… Postcode: ………………………............

Telephone No: (h) ……………………………...................…… m) ………………………………………...................

E-mail: ………………………………………………………………………….............................................................

Cricket Club: ……………………………………………………........................................................................…

Prior attendance on First Aid course: Yes / No Date: ………………….................................

Prior attendance on GP & CP course: Yes / No Date: ………………….................................

CRB check completed: Yes / No Date: ………………….................................

I wish to attend the following course (please tick appropriate box):

COURSE	VENUE	DATES	COST	√
UKCC 1			£180
UKCC 2			£290
ECB1 Conversion			£ 190
CDW			£ 25

Ethnicity (please tick appropriate box):

Bangladeshi	Black African	Black Carrib	Black Other
Chinese	Indian	Pakistani	Asian Other
White	Other (please state)

Do you have a disability:    Yes / No

If so please state:                 PD: Physical disability / LD: Learning disability / MD: Multiple disability /
                                                     HI: Hearing impairment / VI: Visual Impairment / O: Other

Please indicate how you intend to use the qualification:

Please indicate how the fees have been sourced:    Private / Club / Community Chest / Other

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Please complete this application form in full and return it together with a cheque made payable to The Cricket Board

of Wales Ltd for the appropriate course fee to contact on course details.

We will confirm receipt of your application via email. Fees are non refundable after confirmation on the course.