Please completeALLsections of the form

Step By Step Counselling Course
Application Form –London 2017 – Course provider – Image.

Applicant Information

Forename(as it will appear on certificate):
Surname (as it will appear on certificate):
Date of birth: / Gender:
Phone:
Mobile: / Phone:
Current address:
Town/ City: / County: / Post Code:
Email address:

Section 1: Training

Please state any relevant training with dates:
Please state any qualifications you currently hold:

Section 2:Experience

Please state your experience in counselling and/or pastoral care with dates:
Why do you want to come on the course?
If you are coming as part of a Pregnancy Centre/ Church please provide details below:
How did you hear about the course?

Reference: Details of person recommending you for the course:

(e.g. Church Leader or Pregnancy Centre Manager):
Name and position: / Address or email: / Phone:
The following information is required by Open Awards:

Section 3: Diversity and Equal Opportunities Monitoring

Ethnicity – Please tick
1 / White British / 10 / Bangladeshi
2 / White Irish / 11 / Any Other Asian Background
3 / Any Other White Background / 12 / Caribbean
4 / Mixed White and Black Caribbean / 13 / African
5 / Mixed White and Black African / 14 / Any Other Black Background
6 / Mixed White and Asian / 15 / Chinese
7 / Any Other Mixed Background / 16 / Any Other Ethnic Group
8 / Indian / 99 / Not Stated
9 / Pakistani
Employment Status – Please tick
ST / Student (Full Time) / FT / Full Time Employed
PT / Part Time Employment / NS / Not Stated
RE / Registered Unemployed (Seeking Work) / UN / Unwaged (Not Seeking Work)
Access to learning – Please tick / YES NO
1 / Do you consider yourselfto have anything that may affect your access to learning? For example, a learning difficulty (eg dyslexia), a disability (eg deafness or needing wheelchair access) and/or a language barrier (not fluent in English)
2 / If yes, please state below so that we can make sure you have any additional support you may require. The information you give will only be shared with course tutors and Open Awards:

AN IMPORTANT NOTE: If you have experienced abortion, miscarriage or child loss the material on this course may affect you. This is a course for training and, whilst the tutors are able to signpost for support if it is needed,WE STRONGLY RECOMMEND THAT YOU DO NOT CONSIDER SUPPORTING OTHERS IF YOU HAVE UNRESOLVED ISSUES RELATING TO YOUR OWN LOSS. If you are uncertain about whether to apply or would like help to think this through, contact: Marcia Jones, Course Leader, Image Training London – 07753 784 573

Having read the course information, I am applying for a place on the image course and verify that the information above is correct.
I transfer / £50 / Account no81670670 , Sortcode40-07-30,
Reference: Options Training
Signed / Date
Signed: / Date:

Please EMAIL booking form to nd transfer £50.00 non-refundable deposit once your place has been confirmed.

Registered charity number 1141832,

Charity No. 1112366