Ring 2 £550

First Name:

Last Name:

E-Mail:

Phone:

Street:

City:

State or province:

Postal/Zip Code:

What is your dietary preference

Select One
omnivore
vegetarian
vegan
something else

Do you have any dietary needs or allergies that we need to take into consideration? If you need more space please send us an email: artofmentoringuk@gmail.com

Do you have any medical issues that you would like us to be aware of? If you need more space please email us: artofmentoringuk@gmail.com to give further details.

Please select any of the following illnesses or conditions you may have had
asthma
diabetes
high blood pressure
epilepsy
stomach disorders
arthritis
heart conditions
allergies
none of the above

Or any physical limitations we should be aware of? If you need more space please email us: artofmentoringuk@gmail.com

Do you consent to receiving any necessary emergency medical treatment for any injury or illness during the Art of Mentoring Week 2012

Select One
I DO consent
I do NOT consent

Are you OK with us using photos that you appear in taken during the week on our website or other publicity? These can be really helpful in helping convey what the week entails to others and may be used to aid us obtaining funding.

Select One
yes
no

To help us design the programme to meet the groups needs, here are a few optional additional questions: ... How active do you like to be?

other experience with 8-shields model

Do you have any goals for the week?

More space for your goals...

More space for your goals...

Your non-refundable deposit:

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I understand you can not hold my place more than a week without receiving a deposit of £150

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