Module Registration Form

Single Module Application

Use this form to apply for a single module rather than the full Certificate programme.
Name

First Name(s)Surname
Birth Date*

DayMonthYear
Sex
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
E-mail*
example@example.com
Mobile Number
Phone Number

Area CodePhone Number
Emergency Contact Name*
Emergency Contact Number*
Church*
Vicar / Supervisor's Name*
Vicar / Supervisor's Email*
Vicar / Supervisor's Phone Number*
Deanery*
Module*
Would you like to take the Assignments for the module?**

YesNo
*If yes, we will need to ask your vicar (or someone else in authority in a vacancy) for their support for you to take the course as they will need to be present for the delivery of, and comment on, your specialist module assignment. Please note however that Certificate does not imply or confer any authority to minister anywhere in the Diocese including your own church, that is entirely in the gift of your Vicar as is the responsiblity for ensuring that you have the correct level of DBS check and safeguarding training in place should they invite you to minister.
I have read and understood the Information on the Course Website*

YesNo
I understand that I am applying to just take one module, as selected above*

YesNo
Are you happy for your first name and parish to appear on a diocesan map that only other course participants can see?

YesNo
Are you happy for your email address to be shared with other course participants?

YesNo
Safeguarding Declaration*
Please state if you, or anyone in your household, has ever been refused a DBS certificate or has been implicated in any Safeguarding situation. if not please state 'Nothing to declare'. Please note that as we process your application we will send your details to the Diocesan Safeguarding team to check that there are no issues we need to be aware of.
Signature*

Clear
By signing this form you are stating that you have read and understood all the information and that everything you have stated is true and accurate to the best of your knowledge.
Date*

DayMonthYear
Date
Should be Empty:

Single Module Application