Postgraduate Certificate in Practice Based Play Therapy Online Application Form

Welcome to the Online Application area for NUI Galway's Adult & Continuing Education Programmes.

Closing Date for application to this programme is 5pm, Thursday June 7th, 2012.

There are two steps in this Application Process:
1. Fill in an Online Application Form, see below.
2. Then post in Relevant Supporting Documentation, see below.

1. Online Application:
Please note that you do not have the facility to "save" the application and come back to work on it at a later stage, it must be completed in one sitting, it is recommended therefore, that you scroll down through the form initially and look at it carefully before you start to complete it. Thank you.

(Those marked with * must be answered)

1) Have you previously studied at NUI Galway?

Yes

No

If you selected "yes" please specify what year you were registered:

2) Surname*:

3) First Name(s)*:

4) Gender*:

Male

Female

5) Date of Birth*:

Format DD/MM/YYYY

6) Country of Birth*:

7) Nationality*:

8) PPS Number*:

9) Email Address*:
(PLEASE ENSURE YOU PROVIDE A VALID EMAIL ADDRESS AS ANY FURTHER CORRESPONDENCE FROM NUI GALWAY PRIOR TO REGISTRATION WILL BE EMAILED TO THE EMAIL ADDRESS YOU PROVIDE)

10) Address:

Address 1
Address 2
Address 3
Address 4
Address 5:

11) Telephone (Work):

12) Telephone (Home):

13) Telephone (Mobile)*:

FORMAT 0866001012

14) Payment of Fees (please tick):
If your sponsor is funding or part-funding your participation on this programme, please provide complete contact details in the "other" section below.

Personal Funds   Sponsorship (e.g. Employer, voluntary body etc, - please specify)   Other (please specify)

If you selected "other" please specify:

15) Please provide particular student needs:

Access (wheelchair access, etc. )   Learning Supports (Dyslexia etc.)   Other (please specify)

If you selected "other" please specify:

16) If you have worked with children please describe your experience.

17) Reasons for attending

18) Please provide below details of your current employer:

Employer name:
Date Employment commenced:
State Position/Nature of Work:

19) Please provide below details of your previous employment experience:

Employer 1 name:
Date Employment commenced:
Date Employment ceased:
State Position/Nature of Work:
Employer 2 name:
Date Employment commenced:
Date Employment ceased:
State Position/Nature of Work:
Employer 3 name:
Date Employment commenced:
Date Employment ceased:
State Position/Nature of Work:

20) Please outline any previous qualifications that you have achieved e.g. Degrees, HETAC/FETAC qualifications, any other relevant certificates, etc

Course 1 Title of course/Qualification taken:
Name of Institution attended:
Years of Study From/To
Award result achieved:
Course 2 Title of course/Qualification taken:
Name of Institution attended:
Years of Study From/To
Award result achieved:
Course 3 Title of course/Qualification taken:
Name of Institution attended:
Years of Study From/To
Award result achieved:

21) Please provide below details of two referees one of whom should be your supervisor, current employer or equivalent

Referee 1 name:
Address:
Telephone number:
Referee 2 name:
Address:
Telephone Number: