APPLICATION FORM
Your name
Your job title
1. PLEASE SELECT THE PATHWAY & LEVEL YOU ARE APPLYING FOR (please circle) – for
more information on pathways, see:
http://www.sussex.ac.uk/socialwork/pgstudy/cpd/cpdpathways
Leadership, Management and Supervision in
Postgraduate Certificate / Postgraduate
Children’s Services
Diploma / MA
OR CPD Stand-alone module
Effective Practice in Integrated Children’s
Postgraduate Certificate / Postgraduate
Services
Diploma / MA
OR CPD Stand-alone module
Practice Education
Postgraduate Certificate / Postgraduate
Diploma / MA
OR CPD Stand-alone module
2. PLEASE STATE MODULE/S FOR WHICH YOU ARE APPLYING (for this academic year only)
3. PLEASE GIVE DETAILS HERE OF ANY PRIOR STUDY/CPD MODULES TAKEN AT THE
UNIVERSITY OF SUSSEX IN THE LAST 5 YEARS (THIS WILL HELP US TO ADVISE ON ANY
PRIOR LEARNING THAT COULD BE BROUGHT TO THE NEW AWARD – PG CERT, PG DIP
OR MA)
4. IF YOU ARE APPLYING FOR PRACTICE EDUCATION STAGE 1 OR 2, PLEASE ENTER YOUR
HCPC NUMBER IN THE BOX BELOW (PLEASE ALSO COMPLETE APPENDIX 4 IF YOU ARE
APPLYING FOR PRACTICE EDUCATION STAGE 1 OR 2)
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5. ELIGIBILITY FOR APPLICATION TO PROGRAMME.
PLEASE GIVE DETAILS
I hold a professional or vocational qualification (NVQ level 5
or above) and work in Children’s or Adults’ Services, health,
education or social care.
I am employed or am undertaking voluntary work within
Children’s or Adult Services, health, education or social care
for at least 15 hours a week.
6. PERSONAL DETAILS
Surname:
Title:
Date of Birth:
First Names:
Previous Surname(s) (if applicable):
Work Address:
Home Address:
Post Code:
Post Code:
Mobile No:
(optional)
Daytime Telephone No:
Personal email address (optional)
Work E-mail Address:
Nationality (as on passport)
Country of Birth:
7. WORK HISTORY:
Please detail your current and past job roles starting with the most recent.
Date From MM/YY – MM/YY
Job role and key tasks
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WORK HISTORY CONTINUED:
8. PROFESSIONAL OR VOCATIONAL QUALIFICATIONS – PLEASE LIST HIGHEST
QUALIFICATION FIRST
Title
Awarding Body
Where gained
Year gained
9. OTHER ACADEMIC QUALIFICATIONS
Title
Awarding Body
Award level
Where gained
Year gained
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10. DISABILITY/SPECIFIC LEARNING NEEDS
We encourage you to disclose any disability or medical condition which may affect your future studies. All offers
are made on academic grounds and the information given here will be used to help provide services which meet
your needs.
A. No disability
B. Social/communication impairment/Aspergers
C. Blind/serious visual
impairment
D. Deaf/Serious hearing impairment
E. Long standing illness/condition
F. Mental health condition G. Learning difficulty e.g. dyslexia
H. Physical
impairment/mobility issue
I. Disability not listed
J. Two or more impairments or disabling
conditions
Other (please specify):
Please tick here to confirm this information can be shared with our Student Support Unit
11. ETHNICITY
To assist us with our confidential monitoring please choose one selection from A-E to indicate your ethnic group.
A. White: British
Irish
Any other white background
B. Mixed: White and Black Caribbean
White and Black African
Any other Mixed background
C. Asian or Asian British: Indian
Pakistani
Bangladeshi
Any other Asian background
D. Black or Black British: Caribbean
African
Any other Black background
E. Chinese or other ethnic Group: Chinese
Any other
12. MODULES ON THIS COURSE REQUIRE YOU TO HAVE ACCESS TO A WORK ENVIRONEMNT
(VOLUNTARY OR PAID EMPLOYMENT). PLEASE GIVE DETAILS:
Name:
Address:
Telephone Number:
Job Title:
E-mail Address:
Please can you supply a reference from an employer (or if you are engaged in voluntary work,
your manager). This should act both as a reference and formal agreement that you have been
given permission to undertake any assessment work associated with your studies.
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13. CANDIDATE’S AGREEMENT
I declare that the information I have provided is true. I acknowledge that my acceptance of a place at Sussex
University is subject to the University’s terms and conditions and agree to abide by any University laws that are in
place during my period of study.
Data Protection Declaration
I give my consent for Sussex University to process information related to myself, in accordance with Data Protection
Requirements.
Applicant’s signature:
Date:
14. FUNDING please tick either a) or b)
a) My attendance on this course is nominated and funded by my employing
agency (please complete appendix 1)
B) I am self-funded (please complete appendix 2)
C) I have been accepted for a Bursary – see
http://www.sussex.ac.uk/socialwork/pgstudy/cpd for details.
(please complete appendix 3)
If self funding
Submit completed forms to: PQ Programme Co-ordinator, School of Education and Social Work,
Room 1-2 Essex House, University of Sussex, Falmer, Brighton, BN1 9QQ.
If from East Sussex County Council
Submit completed forms to Jo Stanley, Social Work Education, Fourth Floor, St Marks House, 14
Upperton Road, Eastbourne, BN21 1EP.
If from Brighton and Hove City Council
Submit completed forms to Lindsey Cockram, Workforce Development Team, Brighton & Hove City
Council, 4th Floor, Kings House, Grand Avenue, Hove, BN3 2LS
If from West Sussex County Council
Submit completed forms to Madaleine Owens, Professional Practice Team, Centenary House,
Durrington Lane, Worthing, BN13 2QB
If from any other agency
Please send to your completed form to your Training Manager to be checked and sent on to the
University. PQ Coordinator Room1/2, Essex House, University of Sussex, Falmer, Brighton, BN1
9QQ.
For all enquiries on admissions contact the PQ Coordinator: pqcoord@sussex.ac.uk
Tel 01273 872733.
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Appendix 1
AGENCY AGREEMENT IN SUPPORT OF APPLICATION FOR POSTGRADUATE STUDY AT THE
UNIVERSITY OF SUSSEX
(to be completed by candidate’s Designated Training Manager within the employing agency)
We, the employing agency (name)____________________________________
hereby nominate (candidate’s name) _________________________________
to attend the following course _______________________________________
We agree to the payment of course fees.
We agree that the agency will provide appropriate professional opportunities to assist the
candidate in assignment work.
We agree that the required time will be made available for the candidate to attend the
course and to undertake study and assignment work, as specified in the course
handbook and timetable
It is our considered view that the candidate meets the entry requirements for this course.
It is our considered view that the candidate has the ability and commitment to complete the
required course work.
Designated Training Manager in the employing agency/authorised person:
Name:
Post:
Signature:
Date:
INVOICING DETAILS
Contact details for person to receive invoice:
(For students from Brighton and Hove City Council, East Sussex County
Council and West Sussex County Council this can be left blank.)
Name_____________________________________
Address ___________________________________
__________________________________________
__________________________________________
Phone number______________________________
Appendix 2
SELF FUNDING AGREEMENT IN SUPPORT OF APPLICATION FOR POSTGRADUATE STUDY AT
THE UNIVERSITY OF SUSSEX
(to be completed by candidate)
Course applied for_________________________________________________
I, (students name)____________________________________
Agree to the payment of course fees in full on registration to the module.
Agree that my agency/employer will provide appropriate professional opportunities
to assist in my assignment work.
Agree that I have arranged for the required time will be made available for me to
attend the course and to undertake study and assignment work, as specified in the
course handbook and timetable
Have read and understood the course requirements and consider myself eligible to
take park in the course/s I have specified.
Am aware of the time and commitment this course requires and agree I have set
aside both to complete the module to the best of my ability.
Name:
Signature:
Date:
Appendix 3
BURSARY APPLICATION IN SUPPORT OF POSTGRADUATE STUDY AT THE UNIVERSITY OF
SUSSEX
(to be completed by candidate)
Course applied for_________________________________________________
I, (students name)____________________________________
Agree that I have been accepted for bursary funding to cover the cost of the above
course.
Agree that I have sent my acceptance letter to The University of Sussex Finance
Office.
Agree that I have arranged for the required time will be made available for me to
attend the course and to undertake study and assignment work, as specified in the
course handbook and timetable
Have read and understood the course requirements and consider myself eligible to
take part in the course/s I have specified.
Am aware of the time and commitment this course requires and agree I have set
aside both to complete the module to the best of my ability.
Name:
Signature:
Date:
Appendix 4
ADDITIONAL INFORMATION REQUIRED IF APPLYING FOR PRACTICE EDUCATION
STAGE 1 OR 2
(to be completed by candidate)
STAGE 1
Applicants must:
- have some responsibility for the teaching and assessment of a trainee social worker or other
learner at the time of study
STAGE 2
Applicants must:
- be a registered social worker
- have a minimum of two years' post qualifying social work experience
- be involved in the teaching and assessing of a trainee social worker or some other staff
engaged in social care and/or social work at the time of study
- have achieved Practice Education Stage 1 or the equivalent (this could be the Practice
Teacher Award plus evidence of currency, Enabling Work Based Learning modules)
Stage 1 & 2) I confirm that at the time of
study I will have some responsibility for
the teaching and assessment of a trainee
social worker or other learner at the time
of study.
Stage 2) I confirm that I am a registered
social worker and have included my HCPC
number in this application
Stage 2) I confirm that I have a minimum
of two years' post qualifying social work
experience and have included details in
this application
Stage 2) I confirm that I have achieved
Practice Education Stage 1 or equivalent
(please give details)
Stage 2) Please give details of prior
experience of supervising students
Applicant’s signature:
Date: