COURSE APPLICATION FORM

1.YEAR GROUP APPLIED FOR (please tick one):

Year 1 - Ipswich
Year 1 - Norwich
*Year 2 - Ipswich
*Year 2 - Norwich
*Year 3 - Ipswich
*Year 3 - Norwich

*NB Application under APEL (accreditation of prior experience and learning) see Section 8

2.PERSONAL DETAILS

Name
Address
Phone Numbers
Email
Date of Birth
Gender
Ethnicity

3.HEALTH DETAILS

Have you had any physical, psychological or emotional condition or any addictions for which you have been treated in the last five years? If yes please detail:

4.EDUCATIONAL QUALIFICATIONS

Institution / Qualification type / Grade / Date

5.EMPLOYMENT HISTORY

Dates (most recent first) / Name of employer / Position

6.RELEVANT PREVIOUS TRAINING

Date / Institution / Qualification

7.PERSONAL STATEMENTS

7.1 Please tell us (in approx. 500 words) why you wish to undertake this training at this point in your life and what use you intend to make of the qualification.

7.2 Please assess (in approx 500 words) your strengths and personal qualities that you feel will assist you as a practitioner and also discuss any characteristics you have which you feel may impede you.

8.APEL (accrediting prior experience and learning)

*If you are applying to one of our courses via APEL please see the accompanying criteria and list below the documents you are enclosing in support of your application:

9.REFERENCES

Please supply two references. List details of your referees here and forward the reference form to them for completion. One reference should be from your current/most recent employer or academic institution and the other from another source. References from family and friends will not be accepted.

Name
Address
Email
Relationship to you
Name
Address
Email
Relationship to you

10.CRIMINAL CONVICTIONS

Please detail below any criminal convictions in the last 5 years:

11.DECLARATION

I confirm that the information given in this form is true, complete and accurate. No information requested or other relevant information has been omitted.

I confirm I have declared all medical, physical and psychological conditions, both past and current, which could potentiallyaffect my ability to effectively engage in psychotherapeutic counselling training.

Signed:Date:

On completion:

Please email your completed form and a completed Ethnic Diversity Form to Matrix Administrator Alix Roos

Forward the reference forms to your two referees and request that they submit their completed forms to the email address above

You will receive confirmation that we have received your application and we will give you details of the next steps.

If you have any queries please feel free to contact Alix Roos

Data protection

Under the terms of the Data Protection Act 1988 the personal information supplied by you will be treated in confidence but will be used for registering andstatistical purposes.

MATRIX FEES 2014-2015

Year 1
£3750 + £750 VAT = TOTAL£4,500
Year 2
£4583.34 + £916.66 VAT = TOTAL£5,500
APEL students: £4983.34 + £996.66 VAT =TOTAL£5,980
Year 3
£4916.67 + £983.33 VAT =TOTAL£5,900
APEL students: £5500 + £1100 VAT = TOTAL £6,600
Consolidation/Supplementary YearFee
£604.17 + £120.83VAT = TOTAL £725

EQUALITY AND DIVERSITY MONITORING FORM

Matrix College is committed to the development of positive policies to promote equal opportunities in the delivery of our training, regardless of race, disability, gender, belief or religion, age or sexual orientation. This commitment will apply to our selection and assessment processes.

In order to monitor and ensure the successful implementation of this policy, all candidates for training are requested to complete this Equality and Diversity Monitoring Form.

Your answers will be treated confidentially and will not affect your training application in any way.

Do you consider yourself to be disabled?
Please give further details in the space below if you wish to:
Is there any information that we need in order to ensure you a fair selection or training process?

I would describe my ethnic origin as indicated with “x” below:

(Please note: Matrix College is required to provide this information for all students who register with Middlesex University)

Ethnicity / x / Code / Ethnicity / x / Code
Asian/Asian British Indian / 5 / Not given (EU/Overseas domicile) / 99
Asian/Asian British Pakistani / 6 / Not given (UK domicile) / 98
Asian/Asian British Bangladeshi / 7 / Other Asian background / 10
Black/Black African / 3 / Other Black background / 4
Black/Black British Caribbean / 2 / Other Ethnic background / 9
Chinese or other ethnic group / 8 / Other Mixed background / 16
Information refused / 0 / Other White background / 19
Mixed-white & Asian / 15 / White / 1
Mixed-white & Black African / 14 / White-British / 11
Mixed-white & Black Caribbean / 13 / White-Irish / 12
Not given (EU/Overseas domicile) / 90
Name: / Date:

Please return this form together with your Matrix Student Application Form

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