Application Form
Integrated Collaborative Practice Programme (ICP)
Leading to
NUI Certificate in Community Education and Equality Studies
Level 8
Name:
Job Title:
Length of Time in current role:
Organisation:
Address:
Tel:
Email:
1. YOUR POSITION AND MAIN WORK ACTIVITY
1.1 Please outline your position in the organisation. How long you have been in the role? Briefly
describe your main work activity and your responsibilities.
1
1.2 Please Summarise previous work and other experience that you consider relevant to the
programme.
1.3 This programme will require a high level of commitment and participation from all
participants. Please outline the specific contribution you can make to making this possible,
taking account of the unique insights you can bring from your work, and also taking account of
work constraints.
2. PREVIOUS DEVELOPMENT
Please give details of relevant training and qualifications including summaries of programme
content, dates of attendance/completion, and provider institutions/organisations
3. ABOUT YOU
Please identify and outline relevant personal learning & development needs and what you hope
to achieve from participating in this programme.
4. ABOUT YOUR ORGANISATION AND YOUR ROLE
4.1 Please indicate the specific leadership and collaboration challenges that you face within your
organisational role and outline how you believe this course could support you within your role.
4.2 Describe additional strategic challenges that your organisation faces.
Please include only challenges that are different from 4.1 above
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Print Name
______________________________
Signature
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Date
5. FURTHER INFORMATION
Information about the DATF Bursary:
While the overall cost of the ICP programme is subsidised through the Southside Partnership
Training Network, and the Dun Laoghaire Rathdown Drug and Alcohol Task Force, there is an
enrolment fee of €800. However, there is also a Bursary Scheme that can cover 60-100% of the
enrolment fee and course participants therefore are advised to include a support form from their
employer.
Bursary conditions
1.
2.
3.
4.
5.
Completed course application form
Completed support form from employer
Applicant is living and/or working in the DLR area (confirmed by employer)
The applicant’s employer provides relevant personal, social or health related services in
the DLR area
Employer confirms the applicant will have protected course time for the duration of the
programme.
The closing date for applications is Friday July 10th 2015. All applications will be
reviewed by our steering committee and successful applicants will be informed by
July 31th 2015.
Please send the completed application as well as the employer support form by post or by email to
Marie Kavanagh from Southside Partnership Training Network:
Marie Kavanagh
Administrator / Southside Partnership Training Network
The Old Post Office
7 Rock Hill, Main Street
Blackrock
Co. Dublin
Email: marie.kavanagh@sspship.ie
If you have any further queries please contact Marie Kavanagh or
Lisa Sieger-Jamison of Southside Partnership Training Network on 01 7060100.