UCT Claims Assessors' Short Course Enrolment Form

By submitting this application form to the ASISA Academy, you, the delegate, confirm that all information submitted is true and correct. You understand that the ASISA Academy reserves the right to verify any of the details supplied in this form and that it is necessary for the ASISA Academy to process your personal information, as provided by you in this form (and any subsequent submissions made by you), in order for the ASISA Academy to perform its duties to you. We will never supply your contact details to any third party. The delegate understands and accepts that the ASISA Academy's decision on whether you are accepted or not is final. You hereby consent to: 1) The ASISA Academy contacting you with information about further ASISA Academy courses 2) The ASISA Academy incorporating into its publications any photographs taken of, or feedback provided by, you during the course.

Preferably your direct line/extension.
Please specify any disabilities, special needs or medical conditions that the Academy should be aware of (eg. allergies, etc):

In the case of an emergency, please provide the contact information of a family member / friend: