ChildSafe - Application form

Application Form

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Application to attend a Child Safety Course
Applicant's Name:
Occupation:
Street Address:

Postal Address:


	Postal Code:
Employer/Employment Details:
Telephone number:
Fax number:
Mobile number:
E-Mail:
Specify Training Course:
Date of Training:

Conditions of registration:

1. CAPFSA requests a deposit on registration equal to 50% of course fee. All cheques or postal orders should be made payable to KOVSSA/ CAPFSA.

2. The participant will have to attend all the sessions of the training course in order to qualify for an attendance certificate.

Signed: ________________________

Dated:

____:_____:____

Contact person:
Please forward all completed application forms together with the deposit fee marked for the attention of:

Shehaam Hendricks
Child Accident Prevention Foundation,
PO Box 791, Rondebosch 7701
Tel: (021) 685 5208/ 658 5240
Cell: 083 696 3395
Fax: (021) 685 5331
E- mail: