Application for
Practitioner Coach Award
Accredited by the European Mentoring and Coaching Council
*Note: Please scroll down to find Notes for Completion, Terms and Conditions and Diversity Form.
Personal Details
* Title:
(eg Mr, Mrs, Miss, Ms, Dr)
* First Name:
Middle Initial:
* Surname / Family Name:
Previous Surname:
(if changed)
* Gender:
Male
Female
* Date of Birth:
(use format: 1 January 1980)
* Nationality:
* Address:
* Town / City:
State / County:
* Post Code / ZIP Code:
* Country:
Correspondence Address:
(if different from above)
Town / City:
State / County:
Post Code / ZIP Code:
Country:
* Telephone (day time):
* Telephone (evening):
Mobile:
Fax:
* Electronic Mail Address:
* Payment of Fees:
(who will pay your fees)
Self
Employer/Sponsor
* Curriculum Vitae:
(Please Attach a current CV in Word or.pdf format)
* Copy of Certificates:
(Please attach scanned copies of Relevant Certificates)
* Personal Statement:
(Please attach a personal statement in
Word or.pdf format)
Date Completed:
04 September 2010
* Date Available to Start:
Notes for Guidance:
General
Before completing the form, PLEASE ENSURE THAT YOU READ THESE NOTES FOR GUIDANCE CAREFULLY. You should also read the current PDF/University literature relating to the programme for which you are applying in order to ensure that you are familiar with the curriculum and entry requirements.
The Data Protection Act
This information will be held on computer in accordance with PDF/Middlesex University’s registration under the Data Protection Act and used only for the purpose of education and training, and statistical monitoring.
Individual Details
You are asked to provide general information in this section e.g. contact details. In addition we ask that you specify how your programme fees will be paid e.g. by yourself or by your organisation. If your fees are to be paid by a sponsor then we ask that you attach evidence of this support as well as provide an address for delivery of the invoice.
Date Available to Start
Please state the earliest date you wish to start your programme.
Some
programmes are delivered through Learning Sets and once you are available for study you will be assigned to the next available Learning Set. Please be patient as the formation of these Sets requires a certain minimum number and you may have to wait until a place becomes available.
Work Experience
Please provide a full CV including your education and work experience. In addition, please provide a scanned copy of your most recent academic professional qualifications and any H.E. level qualifications.
Terms and Conditions
A list is given of the terms and conditions required by the PDF. These are in addition to the university general terms and conditions for postgraduate students. Please read them carefully.
Declaration
Any offer of a place you may receive is made on the understanding that in accepting it you agree to abide by the rules and regulations of the PDF and MDX University, and by signing this form you are confirming your agreement to this.
Personal Statement
Please ensure that you enclose a short personal statement (approximately one side A4) with your application form. Your statement should outline why you wish to undertake this programme. You
must
submit a personal statement to be considered for the programme.
Terms and Conditions for
Candidates Undertaking Study with the PDF/MDX
Professional Development Programme
:
.
The PDF undertake to make available the learning support and resources required to allow the candidate to complete their studies. Details of the support will be provided online on the PDF Learning Net. It is the student’s responsibility to ensure they access this support and resource.
.
T
he PDF will invoice candidates for the agreed annual fee at the beginning of their period of study and, if appropriate, once a year thereafter on the anniversary of the student’s registration for their studies. All candidates are required to pay these fees within four weeks of the date of invoice. Failure to pay fees can result in the withdrawal of all tutorial support and disabling of passwords and usernames for electronic learning resources.
.
A
ll candidates will have access to online discussion forums on PDF Learning Net. Access to these resources is dependent upon the student conducting themselves in a respectful and supportive manner to other members of their on-line learning community.
.
T
he Learning Net is a closed learning environment. It is the responsibility of each member of the leaning community to
maintain this environment. Usernames and passwords assigned to candidates for electronic resources are for the use of that student only and should not be passed to non-members of the Learning Net. Failure to comply with this restriction can result in the withdrawal of such resources.
.
I
f the student decides to leave their programme of study prior to its completion then PDF must be informed by email to their Academic Advisor, or Programme Coordinator. They must ensure they have an email reply confirming their decision (without this reply, students should not consider the email successfully delivered).
.
If
the period of study extends beyond that specified by the candidates programme, then PDF may charge additional fees for every additional semester until the final submission and assessment has been completed. The student should contact the Academic Advisor for details of these additional fees.
Declaration
:
I confirm that, to the best of my knowledge, the information given in this form is correct and complete. I have read the instructions, in particular those relating to this section. I understand what they say, and agree to abide by the conditions set out there, which I accept as conditions of this application.
*
I agree
Cancel applicaiton
Equal Opportunities Monitoring Form
CONFIDENTIAL
In order to help us monitor the implementation of our
Valuing Diversity Policy
, please complete this questionnaire and return it with your application form. Your responses will not be made known to any member of the assessment team and this form will be kept separate from your programme application. The information you provide will be treated as
confidential
and used in anonymised format for Equal Opportunities monitoring. Some of the data may also be used to compile returns the University is required to make to the Higher Education Statistics Agency (HESA).
Please tick the boxes or fill in information as appropriate:
*
Marital Status:
Married / civil partnered
Divorced / separated
Single
Widowed
*
Ethnic Origin:
(Please indicate the most appropriate category)
White - British
White - Irish
Other White background
Mixed – White and Black - Caribbean
Mixed – White and Black - African
Mixed – White and Asian
Other Mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Other Asian background
Black or Black British - Caribbean
Black or Black British - African
Other Black background
Chinese or other ethnic background -- Chinese
Other ethnic background
Information refused
*
Are you Disabled: *
Yes
No
Disability:
(If you are disabled, please select the most appropriate statement)
You have dyslexia
You are blind/are partially sighted
You are deaf/have a hearing impairment
You are a wheelchair user/have mobility difficulties
You need personal care support
You have mental health difficulties
You have an unseen disability, e.g. diabetes, epilepsy, asthma
You have two or more of the above disabilities/special needs
You have a disability not listed above
The data you have provided will be stored securely on our computerised information system.
Thank you for taking the time to complete this form.
CONFIDENTIAL