Registration Form for
Professional Development
2008/2009
Literacy Matters
If you have studied at Edge Hill before,
please state your Student ID Number:
1. Personal Details
Surname: Title (Mr, Mrs, Miss, Ms, etc):
Previous Surname
First Names:
(if applicable):
Gender: Date of Birth: Nationality:
Home Address:
Postcode: Country of Residence:
Home telephone: Mobile:
Email:
2. Award, Pathway and Module Details
Target Award (including Pathway): Postgraduate Certificate in Education
Module Code: CPD3726
Module Title: Developing Professional Practice – Return to Teaching
3. Employment
Type of school/setting (please tick as appropriate):
Current occupation: ______________________________________
□ State □ Independent
Employer’s address: _____________________________________ □ Primary □ Secondary
□ Early Years □ Other
______________________________________________________
If teaching, please state:
__________________________Postcode: ___________________ 1. Age range: __________________________________
Telephone number: ______________________________________ 2. Number of years teaching experience: ____________
4. Study Background
Do you hold Qualified Teacher Status? □ Yes □ No
If yes, please state your DCSF/ GTC number: _________________________________________________________________
Have you previously studied a higher education course (ie above A level) in the UK for at least 6 months? □ Yes □ No
Please state your highest current qualification
(e.g. PhD, PGCE, BA/BSc, CertEd, other): __________________________________________________________________
5a. Equal Opportunities Monitoring Data – Disability (Optional)
Edge Hill University uses this information to monitor our equal opportunities and widening participation policies. This information is
used solely for statistical purposes. If you prefer not to provide this information, please tick ‘Decline information’.
Do you have a disability? □ Yes □ No □ Decline information
Are you in receipt of Student Disability Allowance? □ Yes □ No □ Decline information
What is the nature of your disability? ___________________________________________________________________
5b. Equal Opportunities Monitoring Data – Ethnic Group (Optional)
Please choose from the terms printed Asian or Asian British Mixed
here the one which you feel most nearly
describes your ethnic origin: □ 31. Indian □ 41. White/Black Caribbean
□ 10. White □ 32. Pakistani □ 42. White/Black African
□ 14. Irish Traveller □ 33. Bangladeshi □ 43. White Asian
Black or British □ 34. Chinese □ 49. Other Mixed background
□ 21. Caribbean □ 39. Other Asian background
□ 80. Other Ethnic background
□ 22. African
□ Decline information
□ 29. Other
6. Fees
Please confirm how your course fees will be paid:
please tick one:
I am liable for my own fees. I agree that I will pay all appropriate course fees to Edge Hill University.
My fees are covered by an existing partnership agreement between Edge Hill University and:
please specify partner name: Literacy Matters
If the partner is ATL, please also provide your ATL membership number _______________________________________
My fees are to be paid for by a sponsor who has provided written agreement. My sponsor’s details are:
Name and address _________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________ Postcode ______________________________
Contact name _______________________________________________ Telephone
_____________________________
Please note: Your sponsor’s written agreement must be attached to this form
7. Declaration
I confirm that the information given on this form is accurate and complete and no information requested or other significant
information has been omitted. I understand that this information is subject to the provisions of the Data Protection Act 1998.
Signature:. ________________________________________________ Date: ______________________________
Please return this form to:
Collette Cope, Literacy Matters Ltd, 30A Market St, Disley, Cheshire, SK12 2DT
For office use only: PDRF 02 / v1