Church Leadership Application Form Course Please tick which course you would like to study and the mode of delivery. Certificate in Christian Leadership (LLP)CounsellingCertificate in Christian Ministry & Leadership (Elders) Personal Details Surname: Title (Mr/Mrs etc.) Other Names: Sex (M/F): MaleFemale Names you prefer to be called by: Date of Birth: Nationality: House Number/Street: Area/Locality: Town/City: County/Province/State: Country: Postcode/Zip: Tel: Mob: Your Email: Support From Your Church Will your church be paying your course fees? If ‘Yes’ please complete details of your church below: YesNo Name of Church: Address: Church Tel: Church Email: Physical Disability / Learning Difficulty / Health Do you have any physical disability, learning difficulty or health problem that might affect your studies or residential needs? If so, please give details: Emergency Contact Surname: Title (Mr/Mrs etc.) Other name(s): Sex (M/F): MaleFemale Relationship to Applicant: House Number/Street: Area/Locality: Town/City: County/Province/State: Country: Postcode/Zip: Tel: Mob: Email: Academic Qualifications (For Certificate in Church Leadership & Ministry Only) Please list details below (most recent first) of qualifications you have gained. If you have not yet gained the award, please state in the Name of institution column ’pending’. Name of institution and address Dates of attendance (From) Dates of attendance (To) Qualification, subject name and awarding body Date of award Referees Please give us the names and addresses of TWO people to whom we may write (remember to ask them first). One should be your church pastor/leader, the other should be able to comment on your personal and vocational development and/or on your academic ability. Referee 1 Surname: Title (Mr/Mrs etc.) Other name(s): Sex (M/F): MaleFemale Relationship to Applicant: House Number/Street: Area/Locality: Town/City: County/Province/State: Country: Postcode/Zip: Tel: Mob: Email: Referee 2 Surname: Title (Mr/Mrs etc.) Other name(s): Sex (M/F): MaleFemale Relationship to Applicant: House Number/Street: Area/Locality: Town/City: County/Province/State: Country: Postcode/Zip: Tel: Mob: Email: Criminal Convictions BCC has a duty to ensure the safety and security of its students and staff. Please tick the relevant box below: Do you have any criminal convictions? YesNo If 'Yes' please give details with dates (excluding motor offences etc.): Declaration I confirm that the information given on this form is true, complete and accurate and that I have not withheld any information relevant to my application. I understand that in accordance with the Data Protection Act my information will be held electronically. I give my consent to the processing and storing of my data by Birmingham Christian College as detailed within the Student Privacy Notice. I understand that any offer of a place as a student received will be based on the information given in this application and that if I am found to have supplied false information, any such offer will be withdrawn. Signed: Date: Equal Opportunities Monitoring Information Information on ethnicity and/or disability will not be used in reaching a decision on the outcome of your application. Ethnic Origin WhiteBlack/British CaribbeanBlack/British AfricanBlack (Other)Asian/British PakistaniAsian/British BangladeshiAsian/British IndianAsian/British ChineseAsian (Other)White/Black CaribbeanWhite/Black AfricanWhite/AsianOtherDo not wish to specifyNot Known Disabilities (tick all that apply) AutisticBlind/Visually impairedDeaf/Hearing impairedDyslexiaOther Learning DifficultyMental Health needsMobility problemsMultiple disabilitiesUnseen disabilityOther If you selected 'Other' please specify: Finding out about Birmingham Christian College How did you first learn about Birmingham Christian College (please tick)? Internet SearchChurch/PastorFriendCurrent/Former StudentPress AdvertRadio AdvertOther If you selected 'Other' please specify: Additional Information If you would like to be included on our mailing list to receive information and news about the college, special events and other courses of interest please tick this box.