SkillsActive Level 3 Playwork (Endorsed)
Application Form(Agency name)- 2016-17
1PERSONAL DETAILS
Title ......
First name(s)......
Surname/Family Name......
Correspondence address......
......
Postcode......
Main telephone number...... ….Mobile number......
E-mail address......
Male / Female...... Date of Birth......
2CHILDREN’S WORK
Please give brief details of the work that you have undertaken with children from 0 - 13 and your reasons for wishing to undertake this course.
......
......
......
......
......
......
3PERSONAL DECLARATION
Have you ever been convicted or cautioned with respect to a criminal offence? YES/NO
Because of the nature of the course for which you are applying, this application is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. This means you are therefore not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act. In the event of acceptance, failure to disclose such convictions could lead to disciplinary action being taken. Any information given will be treated in the strictest confidence and used solely in relation to this application.Please be aware that for positions involving access to children and young people a system of checking police records for possible criminal background will be implemented.
If YES, please give full details. Please use a separate/additional sheet of paper if necessary.
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......
4CRB/DBS
Please give details of a CRB/DBS check which has been completed within the last two years in conjunction with your placement
CRB/DBS Enhanced Disclosure Number ...... Date......
5ACCREDITATION INFORMATION
Please provide the following details as per the sheet attached on page 3.
Ability Status ……...... … Ethnicity ……...... …......
Employment Status ……...... … SEN ……...... …
6ADDITIONAL LEARNING NEEDS
Physical or other disability or condition which might necessitate special educational arrangements and support (Please supply supporting evidence if possible e.g. Dyslexia statement)
......
7EQUIP Children’s Ministry
Data Protection
Please note that all data supplied will be held securely by CYM and those other agents and persons contracted to deliver the EQUIP Children’s Ministry course. As the data will be shared with those other agencies and individuals (specific details available on request), in order to be accepted on the course it is essential that you give consent to this procedure by signing in section 7.
8 PAYING FOR THE COURSE : The full cost of the course is £725.00. This includes all materials, registration and teaching/learning days, VLE and certification.
Please contact the administrator at the venue that you wish to attend to confirm payment methods
that are available to you. These may be some of them:
Payment options / Cheque / BACs / InvoiceFull payment - £725.00
Instalment - £225.00 initial payment, followed by two payments of £250.00
Payment by sponsor
N.B A payment/ instalment must be received before the agency/CYM is able to release training materials to you.
Sponsor details (required for Sponsor Invoice only)
Title......
Surname......
First name(s)......
Organisation/Church Name......
Invoice Address......
...... Postcode......
Contact Tel No......
E-mail address......
9 I hereby apply to join the course and enclose a cheque for-
£………...... (Please check with your agency for the appropriate
person/organisation to make your cheque payable to)
And/ Or have completed the relevant payment form, arranging for prompt payment, and have read the relevant agency fee policy
PLEASE SIGN HERE:
Signed (Learner)...... Date......
ACCREDITING BODY INFORMATION
You do not need to send this page with your application form.
ABILITY STATUS
Please enter code only
1Candidate considers they have a learning difficulty and / or disability
2Candidate does not consider they have a learning difficulty and /or disability
3No Information Provided
ETHNIC GROUP
Please enter code only
1White – British2White – Irish
3White - any other White Background4Mixed - White and Black Caribbean
5Mixed - White and Black African6Mixed - White Asian
7Mixed - any other mixed background8 Indian
9Pakistani10Bangladeshi
11Any other Asian background12 Caribbean
13African14Any other Black background
15Chinese16Any other ethnic group
99Notstated
EMPLOYMENT STATUS
Please enter code only
STFull-time StudentFTEmployed Full-time
PTEmployed Part-timeUEUnemployed
SPECIAL EDUCATIONAL NEEDS
0 None 1 You have dyslexia
2 You are blind or partially sighted 3 You are deaf or hard of hearing
4 You use a wheelchair or have mobility difficulties 5 You need personal care or assistance
6 You have mental health difficulties7 You have a disability that cannot be seen,
eg. diabetes, epilepsy or heart condition
8 You have two or more of the above
9 You have a disability, special need or medical condition that is not listed above
Please return this form to the agency that you wish to attend. If you have any questions as to where to send your form then please contact:Your Agency 2016/17