<p> Greater London Middlesex West County Scout Council ADULT LEARNING APPLICATION FORM</p><p>Please complete the fields marked * Membership number (if known – see your membership card or the wrapper of Scouting Magazine) Surname:* First Name:* (Or preferred Name) Title: Dr Mr Mrs Ms Miss Module/ Course Name:* Dates & Location:*</p><p>E-mail address: (please print clearly) Telephone No: Home Mobile Address: *</p><p>Post Code: Preferred Method of Contact: Any Mail Email Scouting Role:* Group: District:* County: * Previous Scouting or other relevant experience (ie how long have you been a leader) Accommodation: Required Not Required (only for weekend courses at Paccar. Bunkhouse with breakfast) Special Dietary Needs: </p><p>Further Needs: (e.g. visual, learning and hearing difficulties, religious requirements, etc.) How did you hear about this course? Date of Birth: (day/month/year) Emergency Name: Contact (essential for ALL Telephone: residential events) Address:</p><p>This form can be downloaded from: www.glmwscouts.org.uk/glmw_application_ac.doc Your Training Adviser: Name: Address:</p><p>Please read and sign below</p><p>CANCELLATIONS: Please notify your Local Training Administrator/ Local Training Manager as soon as possible if you are unable to attend. Training within GLMW for GLMW adults is FREE, however charges may apply following non-attendance.</p><p>OUT OF COUNTY APPLICATIONS – please send directly to the County Training Manager (Stuart Hogge, 42 Morley Crescent West, Stanmore, Middlesex, HA7 2LW)</p><p>Cheques should be made payable to: Greater London Middlesex West Scout Council (G.L.M.W. Scout Council)</p><p>JOINING INSTRUCTIONS: These will be sent to you approximately two weeks before the start of the course. Should you not receive them please contact your LTA or LTM.</p><p>Signature...... Date...... </p><p>This form should now be returned to the Local Training Manager</p><p>Andi Childs 76A Slough Road Iver Heath Bucks SL0 0DY</p><p> [email protected]</p><p>The information on this form will be stored under Data Protection and used for SCOUT ADULT LEARNING PURPOSES ONLY Office Use Only: Out of County Only: Paid: Received: Acknowledged:</p>