Group Leader Registration Form

Serial no: ______

Goodfood Toolkit Training

Group Leader registration form

Goodfood Toolkit registration form

Serial no: ______

We greatly appreciate you taking the time to complete this registration form. Some of the information you give may be used as part of a local or regional evaluation of the Goodfood TOOLKIT programme; however this information is strictly confidential and will not be passed on to any other individuals or organisations.

Applicant Details

Your contact details are required to contact you for training and for further follow-up after your training (they will not appear in any report).

A1Name: ______

A2 Address: ______

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______

A3Postcode:______

A4Tel: ______

A5Email: ______

A6Are you male or female 

Your Employment

B1Are you currently -

At work: voluntarySeeking work

At work: employed At college, student

At work: self-employedWholly retired

UnemployedHomemaker

Other,please specify ______

______

B2If you are currently employed please provide the following details about your employer -

Name of employer:______

Your workaddress: ______

______Tel:______

Work email address : ______

Your job title: ______

Details of your post:

______

______

Clientgroup you work with: ______

Name of any project(s) you are involved in:

______

______

Neighbourhood renewal areas:

Please tick if you work in any of the following areas -

Outer West Belfast 

Andersonstown 

Upper Springfield/ Whiterock 

South West Belfast 

Falls/ Clonard 

Inner South Belfast 

Ballybeen 

Inner East Belfast 

Inner North Belfast 

Ardoyne 

Ballysillan 

Greater Shankill 

Other: Please state ______

Past experiences

C1Have you had any previous experience in working with community groups within the last two years? (Tick one box only)

Yes  No 

C2If yes, please provide details of your last working experience with groups:

Group name / Details of your specific role / Approx dates of work
Eg Walking group / Eg. Led group / Eg. Within last 6 months
Eg Cubs / Eg. Cub Scout leader / Eg. Over last 2 years

C3 Have you ATTENDED any courses on the following topics within the last two years? (Tick all that apply)

Nutrition /  / Please give details ______
Food hygiene / 
Community development /  / Please give details
______
Working with groups / 

Cook it!  Please give details______

Food Values 

Other: Please state: ______

C4a Have you ever LED a course (eg cookery course, nutrition course, life skills course, health promotion) within the last two years? (Tick one box only)

Yes  No go to C5

C4b If yes, please list the names of these courses:

______

______

______

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C4c Who were these courses aimed at? (eg mother and toddler groups, school groups, health professionals)

______

C5 Have you any other experience?

______

C6Please give details of your knowledge and interest in food and nutrition:

______

______

D1 Why do you want to become a Goodfood TOOLKIT tutor?

______

______

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D2 How do you hope to use Goodfood TOOLKIT training?

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D3 What do you hope to gain from being a Goodfood TOOLKIT tutor?

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______

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D 4 Do you hope to deliver Goodfood TOOLKIT as part of your job?

Yes No Unsure

Please detail:______

______

______

D5Once trained you will be expected to deliver to at least one group within six months of training, therefore we require a signature from your manager to permit this (see end of form).

I am willing to deliver the Goodfood TOOLKIT programme

toat least one group within six months of my training date.

I am unwilling to deliver the Goodfood TOOLKITprogramme

to at least one group within six months of my training date

D6If you are not delivering Goodfood TOOLKIT as part of your job, how do you hope to deliver Goodfood TOOLKIT, and to whom?

______

______

Planning and Delivering Goodfood TOOLKIT

E1After training, how soon would you be able to start delivering Goodfood TOOLKIT?

______

E2aHave you identified a group(s) you wish to deliver Goodfood TOOLKIT to?

Yes No go to E3

______

______

E2bIs the group(s) newly established?

Yes No Unsure

E2cHow well do you know the group(s)?

Very well Well Not that well Not at all

E2d Is healthy eating an identified need in your group?

Yes No

Background Information

F1Are there other trained Goodfood TOOLKIT Tutors in your workplace?

Yes No

Please provide contact names:

______

______

F2Do you know of anyone you could jointly deliver the programme with?

Yes No

Please provide contact names:

______

______

F3Pleaseadd any additional details or note any concerns that you have about the programme or training:

______

______

______

See overleaf - /-

NB For catering purposes, please state below if you have any therapeutic dietary requirements:

______

Signed: ______Date: ______

Manager’s Signature of Support

I agree that ______will be supported to deliver the Goodfood TOOLKIT programme to at least one group within six months of undertaking the training.

Signed: ______Designation: ______

Date: ______

Name (Please print): ______

Thank you for taking the time to complete this form

Goodfood Toolkit registration form