1.PERSONAL DETAILS
Name:
Address:
Postcode:
Telephone numbers (home, work, mobile) :
E-mail(please print clearly):
Date of Birth (optional) :
2.CBCS TRAINING
How did you hear about CBCS Training?
Why do you wish to undertake this training
a) To work with CBCS as a volunteer: □
b) For your own Professional Development as: (please specify) □
c) Other (please specify): □
3.PLEASE TELL US ABOUT ANY SIGNFICANT BEREAVEMENT OR LOSS YOU HAVE
EXPERIENCED:
During the course, trainees will be encouraged to work with their own experiences of loss. It is therefore generally recommended that people do not plan to undertake this course if they have recently experienced a significant bereavement. Prospective trainees can discuss any concerns or questions they may have in confidence with a CBCS staff member prior to submitting this form. If you wish to do this, please contact the National Office.
4.WHAT IS YOUR INTEREST IN SUPPORTING CHILDREN AND YOUNG PEOPLE WHO
ARE BEREAVED?
5.WHAT SKILLS AND QUALITIES COULD YOUBRING TO THE TRAINING GROUP?
6.WHAT SUPPORT DO YOU HAVE IN PLACE THAT WILL ENABLE YOU TO
MEET THE DEMANDS* OF THIS TRAINING?
* time commitment, written work, emotional availability
7.ONCE YOUR TRAINING IS COMPLETED, WHAT SUPPORT MECHANISMS DO YOU
HAVE IN PLACE THAT WILL ENABLE YOU TO PUT YOUR NEW SKILLS AND
KNOWLEDGE INTO PRACTICE?
8.PREVIOUS TRAINING / QUALIFICATIONS
Counselling/Counselling Skills Qualifications, or other relevant courses, please specify
Title of Course / Length of Course(e.g. number of days/hours/years) / Grade/Level
(e.g. Certificate, HNC, Diploma) / Date of Award / Date due to be completed
9.SUPPORT FOR LEARNING
In order for us to make adequate provision to support your learning please would you comment if
any of the following apply to you:
Comment:
Blind/partially sighted
Hearing impaired
Dyslexia
Wheel chair user/mobility difficulties
Mental health difficulties/illness
Medical conditions
Other
10.PREVIOUS EXPERIENCE IN HELPING ROLES
1.Organisation:
Period of Time:Role:
2.Organisation:
Period of Time:Role:
11.SUPERVISED PRACTICE PLACEMENT - You will be expected to enter a supervised practiceplacement as part of the course.
This will be subject to meeting the learning outcomes of units1, 2 and 3, and a readiness-to-
practice assessment. For trainees who plan to volunteer for us this will be in a CBCS service.
If you are undertaking this training for other reasons e.g. your own professional development, it
would be helpful to know what arrangements you will make for a supervised practice placement.
The CBCS Training Administrator will be happy to discuss this with you.
Where do you hope to do the supervised practice placement element of the course?
Full Name of Service/Organisation
1. CBCS service
2. Employer
3. Other
12.FINANCIAL INFORMATION – You may wish to discuss this with your local CBCS service or if
applicable your employer.
How will the course fee of £1,050 be paid? Please tick appropriate box:
By me, the named applicant □ Amount £…………….
Partly by me, partly by my region □ Amount £…………….
Partly by me, partly by my employer □ Amount £…………….
By my employer □ Amount £…………….
Other (please specify) □ Amount £…………….
Contact details of where invoice should be sent:
Name:
Organisation:
Address:
Amount:
13.REFERENCES
Please give the names and addresses of two people who have known you for several years and are willing to act as referees. These should NOT be relatives or friends.
Name:
Relationship
to you:
Address:
Post Code:
Tel No:
E-mail: (if possible) / Referee 1 / Referee 2
DISCLOSURE SCOTLAND CHECK
Please note eligibility for this course is reliant on a satisfactory Protecting Vulnerable People Check.
COURSE DATES: Please check your availability for the entire course.
Selection Day: Saturday 25thMay2013
Course Dates: 22nd/23rd June
24th/25th August
21st/22nd September
23rd/24th November
25th/26th January 2014
1st/2nd March 2014
Signed:Date:______

Thank you for completing this form. Please return it to:

e-mail: Tel. No. 01738 444178

Training Department

Cruse Bereavement Care Scotland - National Office

Suite A, Riverview House,

Friarton Road

PERTH

PH2 8DF

We will acknowledge receipt of your application and will confirm any course details with you. Invoicing and taking up of references is usually within 2-3 weeks prior to commencement of the course. Course fees should be paid in full before the course starts.