Road Traffic Management Course Application

Road Traffic Management Course Application Please complete this form and send to England Athletics with a cheque and a passport photo Please attach a colour passport (unless you already hold a UKA Licence). photograph with Fields marked * must be fully completed. Please use CAPITAL LETTERS. your name and course code written PLEASE NOTE: Once your booking has been completed an email will be sent to the email on the reverse. address you enter below. If you do not have access to email please contact us on 0121 347 6543. Computer generated A list of forthcoming courses is available at www.englandathletics.org/courses images will not be accepted. Gender* Male Female First or given name(s)* Surname or family name* House number* Postcode* Date of Birth* DD MM YYYY Preferred contact number* Email address* For those affiliated to England Athletics please confirm the following: Licence number Club For those not affiliated to England Athletics please confirm the name of your organisation/employer: Organisation Course date: Code: Venue: Fee: (tick payment method below) Payment by cheque payable to ‘England Athletics’, with your name, address and course code on the back. BACS payment to NatWest, Sort Code 60-21-48, Account 59025603, quoting course code and surname as reference. Invoice - please give details below - please note booking will not be processed without an official order reference. Organisation Contact name Address Postcode Tel: Email: Purchase order no. Data Protection. UK Athletics Limited, England Athletics Limited, Scottish Athletics Limited, Welsh Athletics Limited and Athletics Northern Ireland (‘The Athletics Governing Bodies’) may use your personal data (including sensitive personal data) for the purpose of administering your involvement in athletics, and to send you information by post, e-mail or SMS related to those purposes. The Athletics Governing Bodies may share your personal data with each other and other organisations involved in the administration of athletics in carrying out these purposes. The Athletics Governing Bodies would also like to send you the following commercial information which may be of interest to you: Information about the world of athletics and about athletics-related products and services available from or promoted by the Athletics Governing Bodies (including information about athletics events, tickets and special offers, prize draws and competitions), by post, email and SMS. If you do not wish to receive this information, please tick here: Information about specially selected products and services available from current commercial sponsors and partners by post, email and SMS. If you do wish to receive this information, please tick here: UK Athletics will process the data provided by you fairly and lawfully for the purpose of the administration of the officials licensing scheme and in accordance with the Data Protection Act 1999. Equity Policy. It would help the development of our equity policy if you would complete the section below. All information is confidential. Ethnic origin Choose one category from A to E and then tick the appropriate box to indicate your cultural background: A White British Irish Any other white background B Mixed White & black Caribbean White & black African White & Asian Any other mixed background C Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background D Black or black British Caribbean African Any other black background E Chinese or other ethnic group Chinese Any other ethnic group Equality Act: The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. Do you consider yourself to have a disability? Yes No If yes, what is the nature of your disability? Amputee Dis 1 Cerebral Palsy Dis 2 Hearing Impairment Dis 3 Learning Disability Dis 4 Visual Impairment Dis 5 Wheelchair user Dis 6 Dwarf Dis 7 Other Dis 8 Please specify: Please return this form, cheque and a passport colour photograph to England Athletics, Membership Services, Athletics House, Alexander Stadium, Walsall Road, Perry Barr, Birmingham B42 2BE.

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