1) Title*:2) Surname*:3) First Name(s)*:4) 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)5) Address for Correspondence:Address 1Address 2Address 3Address 4County:6) Telephone (Landline):7) Telephone (Mobile)*:FORMAT 08660010128) Particular student needs:Access (wheelchair etc.) Learning Supports (Dyslexia etc.) Other (please specify) If you selected "other" please specify:9) Present occupation (if any):10) Previous Work Experience (if any):11) Voluntary Work/Projects in which you are/have been involved:12) Areas of special Interest in Counselling:13) Leisure Activities:14) Outline how this course might be of benefit to you in a personal sense:15) In what areas of your work/neighbourhood/voluntary organisation do you see a need for counselling skills?16) How did you find out about this Introductory Day?Flyer to place of work Website Friend / Work Colleague Other (please specify) If you selected "other" please specify:
Please forward a workshop fee of €190 (postal money order) by post to Fiona Dwyer, Adult and Continuing Education Office, NUI Galway, by Wednesday, February 13th, 2013
Please check that you have answered all questions. When completed, please press "submit" to send your application, you will then be sent an acknowledgment, so you will know it was successfully submitted. Best of luck with your application.