Pre-Course Form

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Pre-Course Form

This form is completed prior to attending a Dementia Interpreters Course.

Full name. *

E mail address: *

Your company name. *

Date of course *

YYYY

Time of course *

Time

Please tick any of the following medical conditions you have. *

Should you tick any of the below conditions, you must make the trainer aware prior to the commencement of the course. The Dementia Interpreters course uses equipment that will reduce your ability to communicate and move. You should only volunteer to take part as a person with dementia (PIC) if you are happy to have these abilities removed. You take part at your own risk and Dementia Interpreters Ltd or any other associate parties cannot be held responsible for any persona injury arising from the products used during this course.

Existing Back Pain

Epilepsy

Seizures

Migraines

Inner Ear Problems

Any Heart Conditions

Are you Pregnant

None of the above

Please tick here to confirm that you have read and accepted this sections T&C's

Required

Do you give us permission to share the information you have provided here with your facilitator to ensure your Dementia Interpreter course is delivered safely? *

Yes

Do you give us permission to contact you via e mail regarding this course or any other associated products or courses available though associated companies of Dementia Interpreters Ltd. *

Yes

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