Counselling Courses Application Form Course Please tick which course(s) you would like to study. Level 2 Certificate in Counselling SkillsLevel 3 Certificate in Counselling Studies Name/Contact Details Surname: Title (Mr/Mrs etc.) First Name(s): Sex (M/F): MaleFemale Name 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: 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: Education and Training Please list details below (most recent first) of your qualifications. If you have not yet gained the award, please state in the Date of award column ’pending’. Name of institution Dates of attendance (From) Dates of attendance (To) Qualification, subject name and awarding body Date of award Employment / Professional Experience Please list details below (most recent first) of your employment in the last 10 years. Please also list any professional experience relevant to your application (add additional lines if necessary). Name & address of employer Dates (From) Dates (To) Position Held Experience Gained Extra space: Why the Chosen Course? In no more than 200 words, please explain why you wish to pursue a training course in counselling? Referees Please give the name and contact details, preferably email address, of someone to whom we can write for a reference. N.B. We cannot accept a relative as a referee. 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 that are not spent? YesNo If 'Yes' please give details with dates (excluding motor offences etc.): Application Fee This course requires a £15 application fee. You can pay below, by bank transfer (details available on request), or by cheque made payable to Birmingham Christian College. I have paid online.I have paid by bank transfer.I have sent a cheque. 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 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 If you selected 'Other' please specify: 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.