FBRT Pilgrimages: Application Form (per person per event)

To apply for an invitation to the pilgrimage, please fill out the form below, print it out, sign it and then post it to the organisers (FBRT) at the following address:

The Secretary, The Francis Bacon Research Trust,
Roses Farmhouse, Epwell Road, Upper Tysoe,
Warwick, CV35 0TN, England.

N.B. The organisers reserve the right to turn down an application for an invitation.

Please tick, select or fill in the boxes as appropriate:

I wish to apply for an invitation to

Personal Information-1

Title
 First name
 Last name
       
House/Street address
City/Town/Village
County/State/Province
 Postal/Zip Code
Country
Phone (incl. code):
 Fax:
 E-mail:

Personal Information-2
 (This information will be kept confidential.)

I have taken part in previous FBRT pilgrimages: Yes* No

*Please give details:

I have taken part in other workshops and/or pilgrimages with either Peter or Sarah Dawkins:
Yes* No

*Please give details:

I have: good health health problems*

*Please give details (e.g. physical/mental ailments/handicaps):

I am able to walk 1 mile uphill (1 in 10 gradient) unassisted in 30 minutes: Yes No*

I am able to walk 3 miles on the flat unassisted in one hour: Yes No*

I am able to climb 3-4 flights (floors) of stairs unassisted without problems: Yes No*

*Please give details:

Personal Information-2 will not be shared, but please tick the box if you do not wish to share Personal Information-1 with other associated organisations:

 

Signature: ........................................................................ Date: .......................................