Programme Application Form - County Roscommon Disability Support Group

Name *

First

Last

Date of Birth *

DD/MM/YYYY

Phone No. *

Email Address *

Email

Confirm Email

Home address for correspondence *

Select Module(s) you wish to apply for: *

Entry Criteria: No formal qualifications required but competent in spoken and written English. Have reached the standards of knowledge, skill and competence associated with Level 4 of the National Framework of Qualifications. This may have been achieved through a formal qualification or through relevant life and work experience *

I confirm I meet this criteria

Are you currently employed in healthcare? *

Yes
No

If so, what is your job title?

How long have you been employed in this role?

Do you hold a Junior Certificate or equivalent (Level 3 on the Irish NFQ)? *

Yes
No

Do you hold a Leaving Certificate or equivalent (Level 4 on the Irish NFQ)? *

Yes
No

Please list your educational qualifications *

(E.g. Level 5 award, Junior Certificate, Leaving Cert, etc.)

What do you hope to learn from this programme?

If you think you may need additional assistance to successfully complete this programme please tick “Need Assistance” and the Quality & Training Officer will discuss this with you on a confidential one-to-one basis *

Need Assistance
Do Not Need Assistance

I have access to a computer, tablet or mobile device with functioning camera, microphone, and audio (speakers or headset) *

Yes
No

I have a stable internet connection with suitable data allowance *

Yes
No

Are you a medical card holder? *

Yes
No

If yes, you are exempt from certification fees. Please furnish copy of medical card as proof of exemption.

Are you in receipt of social welfare?

Yes
No

If yes, you are exempt from certification fees. Please furnish copy of social welfare receipt as proof of exemption.

I consent to having my contact information be shared with the RSG recruitment team so that I may be contacted about future work opportunities. *

I consent
I do not consent

You may opt out at any time by contacting RSG

Would you like to receive a newsletter email containing future courses and possible job opportunities? *

Yes please
No thanks

You may opt out at any time by contacting RSG

Data Protection: Under the Data Protection Act 1998 and the Data (Amendment) Act 2003 and GDPR May 2018, personal information and assessment material recorded manually and electronically will be stored safely and treated as confidential by County Roscommon Disability Support Group CLG. Such data will be processed fairly for specified purposes and on the basis of the consent of the person concerned or some other legitimate basis laid down by law. All learner information given on this form will be kept confidential and will only be shared for the purposes of authentication, certification and monitoring. For more information visit our privacy page: www.rsg.ie/privacy-training *

I have read, understand and consent to having this website store my submitted information so they can process my application.