Flexible Learning Application Form
Academic year: 2017/2018
Programme Name / CERTIFICATE IN JUNGIAN PSYCHOLOGY WITH ART THERAPYProgramme Code / T120 / Location of Programme / LSAD Clare Street, Limerick
Have you previously studied at LIT, LIT-Tipperary or Tipperary Institute?
/ No Yes Which programme did you study?
Student ID No. / / SurnamePrefix /
Mr Mrs Ms Miss
/ First Name / Permanent HomeAddress / Address for Correspondence
(If different from permanent address)
E-Mail:
/Phone No
/ /Mobile Phone No
/Next of Kin Name
/Date of Birth
/ / / .Relationship
/PPS
Next of Kin Address
(If different from Permanent Address)
/Gender
/ Male / Female Nation of Birth
Nation of Citizenship
Next of Kin Phone
/Mother Tongue
Bank Details Bank details are required for refund purposes.
A/C No
/ Sort Code:Bank Name
Bank Address
Data Protection
LIT fully respects your right to privacy. Any personal information you volunteer to LIT will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act, 1988 & 2003.
Student Declaration (must be signed by all applicants). Please see for the Institute’s Rules and Regulations. I confirm that the information on this form is correct to the best of my knowledge. I agree to abide by the rules and regulations of the Institute.
Signature: ______Date: ______
Office Use only
ID
Education:
Please list in order all places of education attended with dates and details of completion of course. Use extra sheets if necessary
Dates: / Training Institution / Course Title / Qualification Received
Other training courses you have undertaken (including personal growth work undertaken):
Additional Information:
Please give an outline of your interest and experience of Jungian Psychology, and also the Arts. Use extra sheets if necessary
Additional Information Cont’d
Why are you interested in doing this course?In order to facilitate this programme, we need to know if you have any specific needs regarding access to / or delivery of learning materials. We will endeavor to meet these needs as best we can. Please specify such needs: / Title:
Where did you hear of this Programme?
LIT Website: [ ] Mailshot: [ ]Email:[ ] Information Evening:[ ]
Radio: [ ]Local Press:[ ] Till Receipts:[ ]Word of Mouth:[ ]
Road Signs: [ ] Event:[ ] (specify which):
Completed Applications to:
Administrator
Certificate in Jungian Psychology with Art Therapy
Department of Flexible Learning
LIT Thurles Campus, Nenagh Road
Thurles, Co. Tipperary
Tel: +353(0)50428112
E-mail:
Closing date for receipt of completed application forms is 8th September 2017
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