Programme Application

It will take about 10-15 minutes to answer all twelve questions. Please have at hand payment details for the person to whom the invoice should be sent.  All information you supply will be treated in confidence.

Personal Information

First Name

Last Name

Job Title

Organisation

Preferred Contact Points (where we should send information and feedback about the Programme)

Address (Line 1):

Address (Line 2):

Address (Town/County):

Postcode:

Email:

Telephone:

Area of Interest

1.	What programme do you want to enrol for?

2.	How did you first hear about this programme?
	--Click Here--previous participant in the programmeline managercolleaguee mail communicationwebsitearticlejournal advertother

3.	What opportunities have you already had to help you develop in this area?
	Coaching		Course (with  formal qualification)		Mentoring
	Course (informal)		Conference seminar(s)		Other  (please specify below)

	Please give more information about the opportunities you have had below e.g. name, organisation, content and  your learning

4.	Briefly describe the series of events that led to your decision to apply for this programme?

Needs Assessment

5.	What is your main learning priority for the programme?

	What other learning priorities you have for it?

6.	What are your expectations of the Programme leader/trainer?

7.	Outside the formal (one hour) sessions, how much time will you devote to study each week?
	--Click Here--less than an houran hour1-2 hours

Access

8.	Which of the following is your preferred learning style (tick up to two)?
	Activitist		Reflector		Theorist		Pragmatist		Don't know

9.	How do you best learn?  How true are these phrases describe you?
		Very true		True		Partly true		Untrue
	I like new experiences and am enthusiastic about new ideas.
	I tend to act first and consider the consequences later
	I like to look at situations from different perspectives.
	I prefer to collect and consider information and data before drawing your conclusions.
	I like to adapt observations and apply theories.
	I am systematic and logical when thinking through problems.
	I like to try things out.
	I am usually keen (or even impatient) to get to the conclusions.

10.	How much do you enjoy and learn through ...
		lots		quite a lot		a little		not at all
	reading
	doing internet searches
	writing out your ideas
	listening to speakers or lectures
	watching DVDs
	trying our techniques
	watching others at work
	working alone
	completing 'on line' exercises

11.

How will you travel to the venue?

Car

Public transport

Not sure

	What other issues should we be aware of in order to ensure your achieve your programme goal successfully?

	Our premises are fully accessible for people with physical disabilities.  However, should you have any other access requirements that we should be aware of (e.g. visual, audio or learning needs), please state them below.

12.	What else should we know about your needs in order to make this programme a success for you?

Fees

13.	To whom should the invoice for the fee be sent?
	--Click Here--YourselfYour ManagerOther

	Full Name

	Email address

	Address (if different from contact information given earlier)

	Postcode

	Telephone

	Other reference information

Equal Opportunities Monitoring

14.

To ensure we serve a full range of individuals and communities, would you be prepared to provide the following personal information which will be kept in confidence.

Yes, I am happy to provide personal data

No, I do not want to provide any personal data

14.a

Are you?

male

female

14.b	What is your marital status?
	married		single		divorced		widowed		civil partnership		co-habiting

14.c	What age group do you fall into?
	Under 16		18 - 19		25 - 29		45 - 49		60 - 64
	16 - 17		20 - 24		30 - 44		50 - 59

14.d

Which postcode do you live in?

14.e	Are you:
	A British (United Kingdom) Citizen		An EU national		A refugee		An asylum seeker		a foreign student		other

14.f	Which ethnic group do you belong to?
	White British		Mixed Race: White and Asian		Other Asian or Asian British		Gypsy/Traveller
	White Irish		Other Mixed Race		Caribbean		Other (please specify below)
	White (other)		Indian		African
	Mixed Race: White & Black Caribbean		Pakistani		Any other Black or Black British
	Mixed race: White and Black African		Bangladeshi		Chinese

	Please specify your ethnic group here:-

14.h

Is English your first language?

yes

no

14.i	What is your religion?
	Buddist		Hindu		Muslim		No religion
	Christian		Jewish		Sikh		other (please specify below)

	Please specify your religion here:

14.k	Please indicate if you would consider that you have a :-
	physical impairment such as a wheel chair to get around, difficulty using your arms or legs
	sensory impairment such as being blind or having a serious visual or hearing impairment?
	mental health condition such as depression, dementia, schizophrenia)
	learning disability such as Downs syndrome or dyslexia; or cognitive impairment such as autism or head-injury
	long-standing condition such as cancer, HIV, diabetes, chronic heart disease, epilepsy
	drug or alcohol dependency

14.l

What is your sexual orientation?

Heterosexual ('straight')

Homosexual ('gay' man; 'gay' woman or lesbian)

Bisexual

Feedback on this Activity

15.	Completion of the Activity
	How easy was it to complete this activity?	Easy		Quite Easy		Quite difficult		Difficult

16.	Duration of the Activity
	How long did it take to complete this activity?	0-10min		10-15min		15-30hr		over half an hour

	Provide any other  Comments, Feedback and Advice below

On completion, please print a copy for your future reference (Main Menu: File & Print).

Then, press 'submit' to send a copy to Accomplice.

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