Dyslexia Action in Partnership With

DYSLEXIA ACTION IN PARTNERSHIP WITH

REAL TRAINING

CERTIFICATE OF PSYCHOMETRIC TESTING, ASSESSMENT AND ACCESS ARRANGEMENTS (CPT3A)

Verified by the British Psychological Society

APPLICATION FORM

Course Applied for Please tick
CPT3A On Line Course £1760.00
3 Day Intensive Course 27th-29th July2011
Sheffield
PLUS online AAC extension
3 Day Intensive Course 19th-21st October 2011
Sheffield
PLUS online AAC extension
3 Day Intensive Course 28th-30th March 2012
Sheffield
PLUS online AAC extension
Intensive Course £2150.00 Day Rate
Intensive Course £2350 .00 Residential Rate
Personal Details
Full Name: / Title: Mr/Mrs/Miss/Ms/Other:
All Previous Surnames: / Date of Birth:
Current Address: / Telephone No:
Mobile Tel. No:
Fax No:
Post Code: / Email Address:
Current occupation:
Education & Professional Training
University Name:
Degree Title or Awarding Body if Different:
Teacher Training Institution: (if different from your degree)
University Degree: / Dates
From / To
Diplomas, Courses attended:
Miscellaneous Details
Are you able to write in English? YES/NO
Are you a Dyslexia Action Guild Member? YES/NO
How did you hear about the course?
Do you have access to any of the following? (please tick as appropriate)
Multimedia Computer / Email
Computer / Fax
Video / Telephone
Cassette Recorder / Video Camera
Photocopier
References
Please nominate two persons (other than relatives) who have agreed to act as your referee. One must relate to your most recent employment. Upon receipt of satisfactory references you will be sent an offer letter and course details.
Name: / Name:
Occupation: / Occupation:
Company: / Company:
Address: / Address:
Postcode: / Postcode:
Tel. No: Fax: / Tel No: Fax:
Email: / Email:
Relationship: / Relationship:
Financial Details
Who will pay your tuition fees?
Method of payment? / Self
Cheque
Credit Card
Standing Order
Other (please specify)
Disability(this information will not be used to discriminate against you)
Do you have any disabilities which may affect your application/ability to do the course? YES/NO
If so, please describe these disabilities:
And also describe:
a) any reasonable adjustments which you feel should be made to the application process to assist you
in making your request to be considered for the course.
b) any reasonable adjustments which you feel should be made to the course itself or any special
equipment which would enable you to carry out the course.
Declaration: Please read & tick each box, once completed, please sign & date
I understand that the Course Fees must be received in full, or a deposit on or before the first day of the course (please note the deposit element of the fees is non refundable)
I agree that I will not reproduce any part of the course without written permission.
I understand that acceptance of a place must be accompanied by a non-refundable deposit.
I can confirm that in my current place of work I hold up to date Criminal Records Bureau (CRB) Enhanced Disclosure :
NB If this is not the case please note that you will be subject to checking by the Criminal Records Bureau before the course is confirmed. This will take the form of an enhanced disclosure. Further information about the disclosure scheme can be found at (Tel. No. 0870 9090811)

Signature………………………………………… Date……………………………

Please return:

1. Your completed application form

2. Copies of your qualifications

to:

Gaynor Marshall

Dyslexia Action

Knowle House, 4 Norfolk Park Road, Sheffield, S2 3QE

Tel: 0114 2815914 - Fax: 0114 2769197

Email:

Website:

Annex 4.2 2010 1/3