Certificate in Contemporary Living (CCL)

Application Form - 2016

This application form is divided up into the following sections:

A. Personal Details

B. Education Background

C. Work Experience

D. Communication Abilities

E. Health and Wellbeing

F. References

G. CV and Photographs

H.  Declarations

I.  Application Check-list

All sections need to be completed. But please feel free to ask for support if needed.

Section A Personal Details

Name
Date of Birth / Day / Month / Year
Gender (Please Tick) / Male / Female
Home Address:
Phone: Mobile:
Email Address:

The CCL is a course for people with an intellectual disability (I.D.). Can you please confirm that you have an I.D. by ticking the box below.

Yes, I have an intellectual disability

Living Circumstances

Who do you live with?

I live on my own

I live with my parents

I live in supported accommodation

Other (please specify)

______

Section B Education Background

1.  Where did you go to School?

Please indicate which primary school you attended:

______

Please indicate which secondary school you attend/attended:

______

2.  What qualification do you have?

I completed the Applied Junior Cert
I completed the Applied Leaving Cert
I completed a FETAC programme
Please give details of FETAC programmes completed

3.  What training courses (if any) are you doing now?

______

______

4.  What training/education centre (if any) you are attending now?

______

Section C Work Experience

Please list any part time/full time jobs you have/had:

______

Section D Communication and Mobility

1.  Please tell us about particular needs you may have in relation to communication and mobility.

Mobility______

______

Hearing______

______

Sight______

______


Speech______

______

Other______

______

Section E Health and Wellbeing

Please tell us about particular needs you may have in relation to health and wellbeing.

Physical Health ______

______

Mental Health ______

______

Personal Care ______

______

One-to-one support is not provided on the Certificate in Contemporary Living so you will need to bring your own support person/P.A. if one is needed.

Will you need one–to- one support from a support person/P.A. while attending UCC?

Yes No

Section F Referees

A referee is a person who knows you in a professional way, some-body outside of your family or friends. This could include a teacher or tutor who knows you or somebody who has worked with you in a professional capacity. We may contact referees by phone for clarification about their reference if needed.

Please include two references with this application. Please ask your referee to comment on the following:

1.  Your suitability for the course.

2.  What you would bring to the course.

3.  What you would gain from the course.

4.  What challenges you might experience on the course.

5.  What level of computer skills you have.

6.  What level of literacy and numeracy skills you have.

7.  What supports you have that will help you complete the course.

8.  What supports you may need to complete the course.

*Please note a follow-up phone call will be made to all referees.

Section G CV and Photos

Please enclose a CV and two passport size photos with your application

Section H Declaration

I certify that all the information supplied is correct and complete.

Signed: ______Date: _____/_____/____

Section I Application Check list

Completed application form
C.V.
2 passport size photographs
2 References

Please return all items listed above by

Thursday 27th April 2016 to:

Andre Kenneally

CCL Course Co-Ordinator,

School of Applied Social Studies

University College, Cork.

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