Part-Time Application/Registration Form

Part-Time Application/Registration Form

Academic year: 2014/2015

Programme Name: Certificate in Adlerian Psychology & Counselling

Programme Code: LC_HAPCP_RCL Campus Location: CLONMEL

Have you previously studied atLIT, LIT-Tipperary, orTipperary Institute?

/ No  Yes 

Which programme did you study?

Student ID No. / Surname
Prefix /

Mr  Mrs  Ms  Miss 

/ First Name
Permanent Home
Address / 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 DetailsBank details are required forrefund purposes.

A/C No

/ Sort Code:
Bank Name
Bank Address
Data Protection
LIT - Tipperary fully respects your right to privacy. Any personal information you volunteer to LIT - Tipperary 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 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.
 I acknowledge that I need to go on personal counselling while undertaking this course
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:
Additional Information:
Please give an outline of your interest and experience of Adlerian Psychology. Use extra sheets if necessary

Additional Information Cont’d

Why are you interested in doing this course?
Please give details of any personal growth work undertaken:
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?
Website: [ ] Mailshot:[ ]Email:[ ] Information Evening:[ ]
Radio: [ ]Local Press:[ ] Till Receipts:[ ]Word of Mouth:[ ]
Road Signs: [ ] Event:[ ] (specify which):
Completed Applications to:
Administrator, Certificate in Adlerian Psychology & Counselling,
Department of Flexible Learning,
LIT Tipperary, Nenagh Road,
Thurles, Co. Tipperary
Tel: (0504) 28112
E-mail:
Closing date for receipt of applications is 5pm on Friday 12thSeptember 2014

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