Home 5 Trainee Application Form Trainee Application FormStep 1 of 812%Name(Required) First Last Your Address(Required) Street Address Address Line 2 City County Post Code Date of Birth(Required) DD slash MM slash YYYY Home Telephone NumberMobile Telephone NumberYour Email Proof of ID(Required) Driving License PassportProof of ID File(Required)Max. file size: 10 MB.Please upload a scan of your ID proof hereWhere did you here about this opportunity?College DetailsCollege Name and Address (Where you are studying) College Address Line 2 City County Post Code Tutor's Name First Last Date Course Started DD slash MM slash YYYY Course DetailsCounsellor / TherapistDo you currently have a counsellor / therapist?(Required) Yes NoCounsellor / Therapists Name First Last Counsellor / Therapist Contact NumberCounsellor / Therapist Email SupervisionDo you currently have a supervisor?(Required) Yes NoSupervisor's Name First Last Supervisor Contact NumberSupervisor Email InformationDo you have BACP student Membership ?(Required) Yes NoBACP Membership File(Required)Max. file size: 10 MB.Please upload BACP membership documentDo you have Insurance ?(Required) Yes NoInsurance File(Required)Max. file size: 10 MB.Please upload Insurance documentDo you have a DBS report ?(Required) Yes NoDBS File(Required)Max. file size: 10 MB.Please upload DBS documentDo you have a fitness to practice certificate?(Required) Yes NoFitness to practice File(Required)Max. file size: 10 MB.Please upload fitness to practice documentHealthDo you have a disability or special needs? Yes NoPlease provide details about your disability or special needsHave you any illness, or do you take any medication, that we should be aware for example, epilepsy or asthma? (We ask this question to ensure we know about any support needs you may have when you start volunteering with us and to ensure your safety)Do you have any allergies? Yes NoPlease provide details of your allergiesEmergency ContactName of Emergency Contact First Last Emergency Contact NumberRelationshipAvailabilityWe operate from two centres, one in Rochdale (Bury Road, OL11 4EE) and Shaw (Beal Lane, OL2 8PH). Please indicate your availability for each centre, if you wish to only work at one, leave to other blankShaw (Beal Lane, OL2 8PH)Mondays at Shaw AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Tuesdays at Shaw AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Wednesdays at Shaw AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Thursdays at Shaw AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Fridays at Shaw AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Rochdale (Bury Road, OL11 4EE)Mondays at Rochdale AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Tuesdays at Rochdale AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Wednesdays at Rochdale AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Thursdays at Rochdale AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Fridays at Rochdale AM (9am to 12noon) PM (1pm to 5pm) Evening (5pm to 8pm)Qualifications & EmploymentQualifications (Please provide details of any relevant qualifications, level and awarding body. Use the + button to add more rows.) Add RemovePlease give details of any jobs you have undertaken where you feel they have provided relevant skills / experience in you undertaking the journey to become and ultimately practice as a counsellor.ReferencesPlease provide details of two referees, who are not related to you. e.g. Employer & colleague First Referee's Name First Referee's Address Street Address Address Line 2 City County Post Code Phone NumberEmail RelationshipSecond Referee's Name Name Second Referee's Address Street Address Address Line 2 City County Post Code Phone NumberEmail RelationshipI confirm that the details provided are accurate and accept that incorrect, misleading and or incomplete information will affect my application.(Required) I confirm that my information is accurate and correct.Signature(Required)Date(Required) DD slash MM slash YYYY Δ
