* Required fields are marked with a red asterisk.

Course applied for:	*
Date of course:	*
Venue:	*
First name:	*
Surname:	*
Job title:	*
Organisation:	< please select > Middlesbrough CFL Middlesbrough CFL Education Middlesbrough Sure Start Middlebrough Borough Council - Other Middlesbrough Primary Care Trust Redcar & Cleveland Children’s services Redcar & Cleveland Education Redcar & Cleveland Sure Start Redcar & Cleveland Borough Council - Other Redcar & Cleveland Primary Care Trust South Tees Acute NHS Trust TEWV NHS Trust CAFCASS 5 Rivers Police Probation Voluntary sector/community Faith group YOS Adult drug treatment agency Other *
Organisation name:	(If Other or Voluntary sector/community)
Work Address	*
Postcode:	*
Contact Telephone:	*
Email:	*
Contact Address (If different to above)
Postcode:
Special needs:
Manager's name:	*
Manager's telephone:	*
Terms: Please tick to confirm you understand that if you are offered a place and do not attend without prior notice, your agency may be liable to a fee of £30.
I understand the terms:	*

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Data Protection Act 1998:
Please note that in accordance with the Data Protection Act 1998 details given in relation to training will only be used for analysis, evaluation, monitoring and statistical purposes. This information may be shared with other agencies in connection with South Tees LSCB activities, plans and policies.