Professional Development and Training Centre

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					Centre for Teacher and Management Training
ILM Award in Workplace Coaching 20011-12

Application Form
Please click on/tick the course you are applying for:

   TD204 (Thurs eve 26 Apr – 28 Jun 12)


PERSONAL DETAILS


First names                                  Family name

Male/Female                                   Date of Birth

Address

                                             Post code

Telephone (day)                              (eve)

email

Current job title/post

Work address

Work email                                   Work tel



2. Special Requirements
If you are Disabled and have special requirements please contact Access to Learning
immediately. 020 7492 2506 email: accesstolearning@citylit.ac.uk.




                                        1
3. MANAGEMENT/TRAINING/MENTORING/COACHING EXPERIENCE (starting with your
current employment.)

   You may attach a CV, if you wish, instead of completing sections 3 and 4

Institution           From/to                   Post              Subject area




                                         2
  4. EDUCATION AND TRAINING


   Awarding   Title of Qualification starting with the most   Where did you   Date
   Body       recent                                          study           awarded




5. PLEASE WRITE A SUPPORTING STATEMENT (USE A SEPARATE SHEET IF NECESSARY)
   EXPLAINING WHY YOU WOULD LIKE TO ATTEND THIS COURSE




                                                 3
Data Protection Act
Information you provide on this form will be used for the purpose described and will be processed in
compliance with the Data Protection Act 1998. Further information about Data Protection is available on
request.



  I confirm that the information given on this form is correct.


  Signed                                                           Date

You should now complete the Equal Opportunities section, then give this form and the
request for a reference to your line manager, or similar, who can confirm you can be
released for the course (if applicable) and can vouch for vocational competence.


Please make sure your form and the reference is returned to :

Post to: Mary La Touche, Teacher and Management Training, City Lit, Keeley Street, London
WC2B 4BA
or
Email to : training @citylit.ac.uk




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Centre for Teacher and Management Training
ILM Level 3 Award in Workplace Coaching

Reference

Name of applicant

Name of referee                                               Job role

Name of organisation

Address of organisation

Contact phone and email

We would be grateful if you could supply a reference in support of this candidate’s application to
be trained as a coach. This should include reference to your own organisation’s internal quality
audits confirming that the candidate’s own practice is to a high standard.




I confirm my agreement for this applicant to participate in the Mentoring Programme. I agree
she/he will be free to attend 100% of the course.

Signed:…         ……………………………………………… (Employer)                              Date
(If returned from your personal email address, the form need not be signed.)


Please return to: Mary La Touche, Teacher and Management Training, City Lit, Keeley Street,
London WC2B 4BA or email: training@citylit.ac.uk



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Section C
Equal Opportunities Monitoring Form

Your Name:


Name of Course:


Course Code:
All information provided on this form is strictly confidential and will be used for monitoring
purposes only



Are you:

Male          Female

Age Group:
Under 21           21-24          25-29            30-39             40-49

 50-59              60+

Ethnicity:
   11 Asian or Asian British – Bangladeshi
   12 Asian or Asian British – Indian
   13 Asian or Asian British – Pakistani
   14 Asian or Asian British – Any Other Asian Background
   15 Black or Black British – African
   16 Black or Black British – Caribbean
   17 Black or Black British – Any Other Black Background
   18 Chinese
   19 Mixed - White & Asian
   20 Mixed - White & Black African
   21 Mixed - White & Black Caribbean
   22 Mixed - Any Other Mixed Background
   23 White - British
   24 White - Irish
   25 White - Any Other White Background
   98 Any Other
   99 Not Known / Not Provided



DISABILITY:

Do you have a disability and/or learning difficulty?

Yes                     No


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If yes please tick as appropriate

   01 Visual Impairment
   02 Hearing Impairment
   03 Disability Affecting Mobility
   04 Other Physical Disability
   05 Other Medical Condition (e.g. Asthma, Diabetes, Epilepsy)
   07 Mental Ill Health
   08 Temporary Disability After Illness (e.g. Post-Viral or Accident)
   09 Profound/Complex Disabilities
   90 Multiple Disabilities
   98 No Disability or Health Problem
   97 Other - please specify if you feel it would be useful for us to know:




Thank you for filling in this form




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posted:10/14/2011
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