MODULE REGISTRATION FORM:
For students on award pathways (CERT/DIP/MA)
returning to take further modules
1. PERSONAL DETAILS
Surname:
Title:
Date of Birth:
First Names:
Previous Surname(s) (if applicable):
Home Address:
Mobile No:
Post Code:
Work E-mail Address:
Daytime Telephone No:
2. AWARD REGISTERED TO: please give award pathway (Leadership & Management;
Effective Practice; or Practice Education) AND level (PG Certificate; PG Diploma; or
MA)
Pathway:
Level:
3. FUNDING: please tick as appropriate
A) My attendance on this course is nominated and funded by my employing
agency
B) I am self-funded
C) I have been accepted for a Bursary – see
http://www.sussex.ac.uk/socialwork/pgstudy/cpd for details.
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4. 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
5. MODULES FOR 2014/15: Please tick which modules you wish to register to - for more
information on pathways and core/option module options see:
http://www.sussex.ac.uk/socialwork/pgstudy/cpd/cpdpathways
Please note: At least fifty per cent of academic credits earned for any award MUST
be from core modules
Module Module Name
code
Credits Dates 2015-16 academic year
904L6
Observing,
Communicating and
Engaging with
Children and Young
People
Practice Education
stage 1
30
6th Oct, 20th Oct; 17th Nov; 8th Dec 2015
19th Jan; 9th Feb; 1st Mar; 12th April 2016
30
22nd September, 20th October, 21st October,
24thNovember, 25th November 2015
20th Jan; 27th Jan, 10th Feb 2016
886L5
Practitioner Research
15
881L5
Risk and Decision
Making
Practice Education
stage 2
ASYE/
Knowledge & Skills
B&H
Professional Learning
Review
Autumn start
Professional Learning
Review
Spring start
Practice Education
stage 1
(May 2016 start)
Dissertation
30
12th Nov, 26th Nov 2015;
28th Jan; 23rd Feb 2016
3rd Feb, 24nd Feb; 9th Mar, 23rd Mar; 6th April, 20th
April; 11th, 25th May 2016
17th Nov, 18th Nov; 8th Dec, 9th Dec 2015
19th Jan, 26th Jan; 9th Feb, 23rd Feb, 24th Feb 2016
1st Feb, 8th Feb, 22nd Feb, 29th Feb, 7th March, 14th
March
899L5
899L6
902L5
903L8B
903L8
899L5B
884L5A
30
15
30
12th Oct, 30th Nov 2015, 8th Feb 2016
30
18th Jan, 15th Feb, 9th May 2016
30
10th May, 11th May; 8th Nov, 9th Nov 2016;
17th Jan, 18th Jan; 7th Feb, 8thFeb 2017
60
18th Jan 2016
Module(s)
selected
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6. 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:
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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 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______________________________
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Appendix 2
ADDITIONAL INFORMATION REQUIRED IF APPLYING FOR PRACTICE EDUCATION
STAGE 1 OR 2 (to be completed by candidate)
IF YOU ARE APPLYING FOR PRACTICE EDUCATION STAGE 1 OR 2, PLEASE ENTER YOUR
HCPC NUMBER IN THE BOX BELOW
-
-
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)
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Stage 2) Please give details of prior
experience of supervising
students
Applicant’s signature:
Date:
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