APPLICATION FORM 2015-2016 Name: ____________________________________________________________________________ Address:__________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Telephone: Home:______________________________ D.O.B: __________________________ Mobile:___________________________ E-mail: _____________________________ Current Employment: ________________________________________________________________ Previous experience of personal counselling and/or personal development work (If any) and any relevant medical history: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________________________________ 1 Brief outline of personal interests, hobbies and activities __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Why are you interested in undertaking this course at this time ? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ What do you hope to do with your learnings on completion of the course? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2 COURSE FEE The total course fee is €1,700 (This includes the residential weekend, all materials/ handouts as well as tea/coffee and biscuits) The fees are paid as follows: [A] €500 Deposit with application form. €600 at Registration on 2nd October, 2015. €600 at end of January 2016. or [B] After paying the €500 Deposit there is an option of paying the remainder of the fee by direct debit (Six payments of €200 over six months - Oct 2013 – March 2014) . or [C] For those who are having their fees paid by a third party, it is the participant’s responsibility to liaise with these bodies and to furnish Fein-Mheas with a letter of approval for payment prior to commencement of the course, and to request any documentation from Fein-Mheas. How do you wish to pay your fees? Please tick your preferred option. [A] [B] [C] DECLARATION I declare that the information given by me in this application form is true and if offered a place on the course I will abide by the terms and conditions of Féin-Mheas. Signature: _____________________________________ Date: _____________________________________ Completed application form to be returned to: Carmel McMahon 4 The Gardens Pennywell Limerick 087- 6799301 Deposit: 500 Euro. Cheques made payable to: ‘Féin-Mheas’ Applications without a Deposit will not be processed. 3