Maryvale Awards: Further Education
Maryvale Institute
Application form
(Maryvale Awards: Further Education)
Course:
Certificate in Catholic Healthcare Chaplaincy (CCHC)
SECTION 1
Title: ……………………………………………………………………………
Surname...... …………………………………...………………………………………………………………
First Name(s)……………………………………………………………………………………………...
Home Address
Line 1: …………………………………………………………………………………………….
Line 2: …………………………………………………………………………………………….
County: …………………………………………………………………………………………….
Country: …………………………………………………………………………………………….
Postcode: …….……..……………………………………………………………………………….
Telephone number: …..……..……….…………………………………………………………….
Mobile number: ……….………………………………………………………………………………….
Email (Please print in capital letters)
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Date of Birth: ……………………Male / Female: …………Nationality: ………......
Religion/Denomination: ………………………………Diocese: …………......
Do you consider yourself to have a disability? YES/NO
If YES, please ensure that you complete the enclosed Disability Support Form and return this to the Disability Support Coordinator. Disclosing a disability will not be a factor in Institute’s decision as to whether or not to offer you a place on the course. However, it is important that the Institute knows if you have any specialist needs in order to provide you with appropriate support and facilities. This information will remain strictly confidential.
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Section 2: Personal Statement
In this space please tell us your main reasons for wishing to undertake this course and ministry to the sick.
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Please list any relevant qualifications or experience
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Section 3:For non-European nationals:
How long have you lived in the UK or other country of the European Union?If the answer to the above question is less than three years please give details of when you arrived and whether you have any study or residence permits:
If applicable give details (start date and length) of any leave to remain, study or Residence Permits which you have.
NB: You will need to present your Residence Permit/Leave to Remain to the Institute prior to commencing any course.
Statement to be signed by all students admitted to the Institute:
I understand that to participate in the CCHC courseI must complete Safeguarding training and Disclosure and Barring Service (DBS) checks, if appropriate, before beginning the course in order to be able to take up a healthcare placement.
I, the undersigned, as a condition of my acceptance onto the Certificate in Catholic Healthcare Chaplaincy course, agree to abide by the Institute’s regulations and course requirements. I give assurance that my conduct throughout the course of study will be consistent with that normally associated with a community of learning and scholarship and with the ethos of the Institute.
Signed …………………………………….……………………. Date …………………………………………..
(A copy of the Institute’s regulations, as well as a statement concerning the ethos of the Institute, can be found on the Maryvale website, or requested from the Institute)
How did you learn about this course?
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Pease return the completed form, together with non returnable application fee of £25 to:
FE Admin Team
Maryvale Institute
Old Oscott Hill, Kingstanding, BirminghamB44 9AG
Cheques payable to Maryvale Institute please – You may also pay by Credit card over the phone or through the website
Section 4:References
Please give us names and contact details of two Referees – one of which must be your Parish Priest – who are willing to supply personal references as to your suitability for this course and ministry.
Name……………………………………………………………………………….………………………………
Email:
Address:
Telephone number:
Name of Parish Priest:……………………………………………………………………………
Parish:
Diocese:
Email:
Address:
Telephone number:
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FOR OFFICE USE
Application fee enclosed: ………………………
Date enrolled:…………………………
Letter of Acceptance sent: ………………… Student Number:…………………......
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Maryvale Institute, Old Oscott Hill, Birmingham B44 9AG tel: 0044 (0) 121 360 8118