<p>Teacher Education and Development ILM Award in Workplace Coaching 2014-15</p><p>Application Form</p><p>Please click on/tick the course you are applying for:</p><p>TD204 ( Classes: 23 Apr – 2nd Jul 2015 plus tutorials and workplace practice to be completed by 31st October 2015)</p><p>PERSONAL DETAILS </p><p>First names Family name </p><p>Male/Female Date of Birth </p><p>Address </p><p>Post code </p><p>Telephone (day) (eve) </p><p> email </p><p>Current job title/post </p><p>Work address </p><p>Work email Work tel </p><p>2. Special Requirements If you are Disabled and have special requirements please contact Access to Learning immediately. 020 7492 2506 email: [email protected].</p><p>1 3. MANAGEMENT/TRAINING/MENTORING/COACHING EXPERIENCE (starting with your current employment.) </p><p>You may attach a CV, if you wish, instead of completing sections 3 and 4</p><p>Institution From/to Post Subject area</p><p>2 4. EDUCATION AND TRAINING </p><p>Awarding Title of Qualification starting with the most Where did you Date Body recent study awarded</p><p>5. PLEASE WRITE A SUPPORTING STATEMENT (USE A SEPARATE SHEET IF NECESSARY) EXPLAINING WHY YOU WOULD LIKE TO ATTEND THIS COURSE</p><p>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.</p><p>I confirm that the information given on this form is correct.</p><p>Signed Date </p><p>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. </p><p>Please make sure your form and the reference is returned by email to </p><p>Wendy Moss, Manager of Teaching and Learning, [email protected]</p><p>4</p><p>Centre for Teacher and Management Training ILM Level 3 Award in Workplace Coaching </p><p>Reference</p><p>Name of applicant </p><p>Name of referee Job role </p><p>Name of organisation </p><p>Address of organisation </p><p>Contact phone and email </p><p>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.</p><p>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.</p><p>Signed:… ……………………………………………… (Employer) Date (If returned from your personal email address, the form need not be signed.)</p><p>Please return to: Wendy Moss, Manager of Teaching and Learning, City Lit, Keeley Street, London WC2B 4BA or email: [email protected]</p><p>5 Section C Equal Opportunities Monitoring Form</p><p>Your Name: </p><p>Name of Course: </p><p>Course Code: All information provided on this form is strictly confidential and will be used for monitoring purposes only</p><p>Are you: </p><p>Male Female </p><p>Age Group: Under 21 21-24 25-29 30-39 40-49 </p><p>50-59 60+ </p><p>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</p><p>DISABILITY:</p><p>Do you have a disability and/or learning difficulty?</p><p>Yes No </p><p>If yes please tick as appropriate 6 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:</p><p>Thank you for filling in this form</p><p>7</p>