Eisteddfod Response and Information Request Form

First Name
Last Name
Address (line 1)
Address (line 2)
Town
County (In Wales)
Other County (Please Specify)
Country (In the UK)
Other Country (Please Specify)
Post Code
Telephone (Home)
Telephone (Work)
E-mail Address
Sex	Male Female
Ethnic Origin
Have you followed any course leading to a degree, A level, GCSE, NVQ or other formal professional or occupational qualification during the last 3 years?	Yes No
Have you benefitted as a Welsh learner from using Acen services before?	Yes No
Are you registered disabled?	Yes No
Please tick ALL the items you'd like. There is NO charge for any of this information. Please register me with Acen and send me a FREE sample copy of the Acen magazine I'd like information about Welsh courses in my area I'd like to know about Welsh nursery groups I'd like to know about Welsh education in schools I'd like to know about workplace Welsh schemes I'd like to know about summer schools I'd like a subscription form for the Lingo! magazine for learners I'd like to know about Welsh examinations I'd like information about CYD I'd like to receive information about S4C programmes I'd like to know about on-line, TV and radio courses I'd like information about the Eisteddfod in Flintshire I know someone who will be performing in the Pavilion or the Literature Pavilion and I'd like details of how to order a video
Did you find this website or the Eisteddfod guide of benefit as a way of learning about the Eisteddfod and the Welsh language.	Yes No