BOOKING FORM 2015
Forest School Programme Certificate (QCF)
Subject to meeting the minimum requirements laid out below, to hold a place please complete this form and return it with a €200 deposit. Online banking details are below or you can pay by cheque made out to Earth Force Education, many thanks. You can then return your form by mail or email to Ciara info@earthforceeducation.com
.
Please send to Earth Force Education, 10 Winetavern Manor, Stratford on Slaney, Co. Wicklow.
Full Name (Mr/Mrs/Miss/Ms) ………………………………………………………...................
Address ……………………………………………………………………………………………………
…………………………………………………………………………………………………………….…..
Postcode …………………………… Daytime telephone no ………………………………………
Mobile …………………………….. E-mail ……………………………………………………………..
Date of Birth ……………………………….
Garda Vetting Clearance: Yes/No Date of most recent Garda Vetting Application: ………….
(no more than 3 years old)
What organisation/s are you vetted with: …………………………
First Aid: You will need a 16 hour Wilderness First Aid Level 2 Certificate or equivalent.
Do you have this: Yes/No Date of expiry: ……………………………….
All participants are required to have a Wilderness First Aid Level 2 First Aid Certificate or equivalent/appropriate 16 hour first aid training. Earth Force Education has arranged a
Wilderness First Aid Level 2 First Aid training with Mountain Training on 9 th th & 10 May, 2015.
(Cost €110 in addition to Forest School Training fees). It is not necessary to do it with us as long as it is the equivalent level of training.
Would you like to attend the First Aid Training: Yes/No

1. Qualifications and/or Experience (please attach extra information)
Please give relevant experience or training of working with young people and children.
2. Employment/Occupation Details:
Name of Employer: ………………………………………………. Position …………………………………
Other: ……………………………………………………………………………………………………………………..
Main Responsibilities: …………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
3.
Can you let us know how you aim to use this Forest School Programme Certificate Level
3 training?
Where did you hear about this Forest School training?
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
Please let us know any other knowledge, interests and experience you may have:

COST & METHOD OF PAYMENT
The total cost of the training is €1,200.00.
A non-refundable deposit of €200 payable to Earth Force Education is required on return of this booking form and to hold a place.
The remaining fee of €1,000 is payable to Earth Force Education 60 days prior to the initial training week.
Please make cheques payable to Earth Force Education and post to Earth Force Education, 10
Winetavern Manor, Stratford on Slaney, Co. Wicklow.
Online bank transfers please to Earth Force Education. * State your name clearly on transfer. E.g. Jim Byrne
BIC: BOFIIE2D IBAN: IE24 BOFI9006 9088 3410 60
Terms and Conditions:
1.
By signing this booking form and returning it to EFE, you agree that any cancellation of your training place would incur a cancellation fee of €200.
€1,200 must be paid 60 days prior to initial training week (by 5 th May 2.
Full amount of
2014).
3.
If cancellation is made less than 30 days prior to initial training start date, 7 cancellation fee of €500 will be retained or requested. th July 2014, a
4.
Cancellations from two weeks before the date of commencement will be charged at the full price.
5.
Once training has commenced there will be no refund.
6.
It is possible to make payments by instalments, once the deposit has been paid in full, please let Ciara know and a payment plan can be agreed.
7.
Please note you have 2 months to return your completed portfolio from the date you attended your final training sessions. After this you will be charged €120.00 re-registration fee.
8.
Cancellations of the Wilderness First Aid Level 2 certificate are also subject to cancellation fee of €50. If you already hold a Wilderness First Aid Level 2 certificate you do not have to attend this element. Please provide a copy of your certificate during your assessment training.
7. We reserve the right to cancel this training if insufficient places have been booked and confirmed.
I acknowledge I have read and agree to the above terms and conditions.
Signed: ……………………………………………………….. Date: ………………………………………….

Circle of Life Rediscovery CIC
Medical form
Please fill out this form as completely and accurately as possible. The facts that you disclose are confidential and provide critical information to provide you with a safe and enjoyable experience with Circle of Life Rediscovery.
Last Name ___________________________ First Name ____________________________
Date of Birth _______________ Age _____________ Male___ Female__
In case of emergency please contact:
Name ________________________________ Relationship ___________________________
Home Tel _____________________________ Mobile
________________________________
Work Tel ______________________________
Or:
Fax __________________________________
Name ________________________________ Relationship ___________________________
Home Tel _____________________________ Mobile
________________________________
Work Tel ______________________________ Fax __________________________________
Name of Doctor ________________________ Address ________________________________
_____________________________________________________________________________
______________________________________ Tel
___________________________________
Please tick any of the following illnesses or conditions you may have had, and add any details on the back of the form:
 asthma
 diabetes
 dizziness
 earaches
 headaches
 high blood pressure
 menstrual difficulties
 freq toothaches
 nosebleeds
 stomach disorders
 epilepsy
 eye problems

 frostbite
 arthritis
 hepatitis
 malaria
 heart conditions
 other

 sleepwalking allergies
Have you undergone any surgery? Yes ____ No ___
If so, please describe the procedure and date _________________________________________
______________________________________________________________________________
Have you been hospitalised in the last three years? Yes ___ No ___
If so, please describe the reason and dates: __________________________________________
______________________________________________________________________________
Please tick any of the following injuries you have had, including description and date of injury.

Back pain: _______________________________________________________________

Concussion: ______________________________________________________________

Fractures: ________________________________________________________________

Sprains / strains: __________________________________________________________

Joint problems: ___________________________________________________________

Other injuries: _________________________________________________ ___________
Do you have any dietary restrictions? Yes ___ No ___
If so, please describe in detail: ______________________________________________________
_______________________________________________________________________________
Do you have any allergies? (e.g. medication, foods like shellfish, nuts, or others, insect bites, dust, etc.) Please describe severity of reaction and list medications needed to control reactions
_______________________________________________________________________________
_______________________________________________________________________________
Are you taking any form of medication? Yes___ No ___
If yes, please give the name of medication, dosage, frequency, and possible side effects:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Are you currently under the care of a physician or other health care practitioner?
Yes__ No__
If yes, please give name and describe the reason:
_______________________________________
_______________________________________________________________________________
Do you have any disabilities? Yes ___ No ___
If so, if so please describe them:
_____________________________________________________
_______________________________________________________________________________
I, __________________________________ (
) declare that the information in this medical form is accurate and truthful. I recognize that providing inaccurate information may endanger myself.
Signed: _______________________________ Date: _____________
Name ______________________________ Email _________________________________
Home Tel ___________________________ Mobile ________________________________
Work Tel ____________________________ Fax ___________________________________
Agreement
1.
I consent to receiving any necessary emergency medical treatment for any injury or illness during the Forest School Programme Certificate (QCF) Level 3 Training.
2.
I do/ do not consent for images of me taken during the training to being used by Circle of Life Rediscovery CIC and Earth Force Education for training and publication purposes.
Signed: ……………………………………………. Date: ………………………………….