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: _______________