<p> Domestic Violence Training Application form</p><p>Course Details</p><p>Course Title: Female Genital Mutilation</p><p>Venue: Buckinghamshire County Council, Walton Street, Aylesbury Date: 19th February 2016</p><p>Applicant Details</p><p>Name: </p><p>Organisation:</p><p>Voluntary or Private Organisation: Yes No </p><p>Address for Correspondence: Telephone Numbers</p><p>Work:</p><p>Postcode: Mobile:</p><p>Email: Prior Knowledge To help us plan the training to meet your needs, please give brief details of: a) Any work experience or previous training in Domestic Violence.</p><p> b) What do you consider your training needs are in respect of Domestic Violence?</p><p>Equal Opportunities Please complete the following section, so that we can monitor if we are meeting the training needs of all groups in the community.</p><p>Do you consider yourself to be (please tick as appropriate)</p><p>Female Male</p><p>White British White Irish White Other Mixed Race White & Black Caribbean Mixed Race White & Black African Mixed Race White & Asian Mixed Race Other Asian British Indian Pakistani Bangladeshi Asian Other Black British Caribbean African Black Other Chinese Other Ethnicity Not Stated Do you consider that you have a Disability?</p><p>Yes No</p><p>Your Needs Do you have any special needs that we need to be made aware of?</p><p>Please abide by the following confidentiality agreement:</p><p>“ Any personal or work situation or case studies that I choose to share during this training will not include any identifying information. Following the training any further action which seems necessary to protect clients, workers or others (e.g. Child Protection referrals) will be my responsibility”</p><p>Signed: </p><p>Invoice for Course</p><p>Address Invoice to be sent to: (if not Internal to Bucks County Council)</p><p>Purchase Order Number ______</p><p>If Bucks County Council Employee</p><p>Please provide an Expenditure Code if you or the payee is an employee of Bucks County Council.</p><p>Expenditure Code: GL______Cost Centre ______</p><p>Cheques</p><p>Please make cheques payable to Buckinghamshire County Council </p><p>Please return to: Vanessa Elmes, Community Safety Administrator, Bucks County Council Walton Street Aylesbury HP20 1UY Tel: 01296 387077 Email: [email protected] </p><p>Please Note: 1. The personal information you have submitted will be treated in strict confidence and will not be used for any other purpose that that stated on this form without your consent. The personal data will be covered by the 1998 Data Protection Act</p><p>2. Payment must be made prior to attending a course and ALL cancellations and non-attendance will be charged at the full amount, including Voluntary and Private Organisations.</p>