Post on 05-Feb-2020
Community Coaching Programme 2015
Please complete fully, using BLOCK letters
Name: ..............................................................................................
Address: ...........................................................................................
......................................................................................................
Date of Birth: ....................................... Gender: Male Female
Telephone: ........................................ Email: ..............................................
PPS Number:
Emergency Contact / Next of Kin: ....................................................................
..............................................................................................................
Education: Please tick the highest level of education achieved.
Primary School Junior Certificate FETAC Level 3 or Equivalent
Leaving Certificate, FETAC Level 4 / 5 or equivalent Post Leaving Certificate Full Trade Qualification/FETAC Level 6 (Major Award) or higher qualification Other: Please give details of any other education/training provision that you
have participated in: ..........................................................................................
Can you use a computer - Microsoft Word and Internet? Yes No
Other Information: Is English your mother Tongue? Yes No
If you answered No, how would you rate your: (please underline which one applies):
i. Spoken English Excellent Very Good Good Fair Unsure
ii. Written English Excellent Very Good Good Fair Unsure
How long have you been unemployed?
Are you in receipt of a jobseekers payment? Yes NoOther Relevant Information:Please indicate if you have any coaching experience or qualifications:______________________________________________________________________________
______________________________________________________________________________
Reasonable Accommodation:Please give details of any medical condition and/or special requirements that we may need to be aware of i.e. wheelchair access; vision/hearing/speech difficulties; dyslexia; epilepsy; other; (see overleaf)
______________________________________________________________________________
______________________________________________________________________________
All applicants for programmes with a Work Experience element which could include working with vulnerable children and/or adults will be screened through the Garda Vetting Process.
Declaration:I confirm that the information given on this form is accurate.
Signed: _______________________________________Date: _______________
Data Protection:I ____________________________________________ agree/ disagree that my data may be shared with consultancy bodies and agencies approved by the Department of Education and Science/VEC/Centre from time to time for purposes of monitoring the impact of the programme. I understand that under the Data Protection Act personal information recorded in manual format and on computer must be stored safely and treated as confidential, that it will never be made available publicly in any way which could identify an individual person and that it will not be used without consent other than for the purpose for which it was gathered.
For Office Use Only:
Received at Office Date:Received by: Name:Offer of Place Yes No Reason if No
Signed: ________________________________________________ Date: _______________