Academy of Play and Child Psychotherapy 
One-day Course – An Introduction to Play Therapy 
  Application Form

Starting date of course………………………….

Course Venue……….………………………

How did you hear about the course? ____________________

1	Personal Details

Surname*	............................................................................................	
First name(s)*	............................................................................................	
Address*	............................................................................................	
	............................................................................................	
City/Town*	............................................................................................	
County	............................................................................................	
Post Code*	............................................................................................	
Phone No (Home)*	............................................................................................	
(Work)	............................................................................................	
(Mobile)	............................................................................................	
E-mail*		
DOB*	............................................................................................	Male/Female*		

2	Education/Training

(Enter up to 4 relevant courses)

Dates of Course	Training Organisation	Course Name	Qualification Obtained	

				

				

Dates of Course	Training Organisation	Course Name	Qualification Obtained	

				

				

3	Experience

If you have worked with children, please describe your experience.

4	Reason for Attending

5	Work experience during the past 5 years

6	Please provide details of any existing  Health Conditions,
 	that we should be aware of eg diabetes, epilepsy, asthma, and 
           any allergies including Food Allergies

To secure your place on the course, please pay by credit/debit card at www.playtherapyshop.com/Miscellaneous Purchases. Please use your surname and venue as the payment reference.

Then return your application form electronically with your payment reference to contact@apac.org.uk 

Signature …………………………………………………..   Date ……………….