Banbury Therapy Group

Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

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DD

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Ethnic Origin *

Please indicate 1 choice

Black or Black British - Caribbean

Black or Black British - African

Other Black background (British or otherwise)

Mixed - White and Black Caribbean (British or otherwise)

Mixed - White and Black African (British or otherwise)

Mixed - White and Asian (British or otherwise)

Other mixed background (British or otherwise)

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Other Asian background (British or otherwise)

White-British

White - Irish

Other White background

Chinese (British or otherwise)

Other (British or otherwise)

No information Given

Please indicate which day and time you wish to apply for. You can indicate more than one day. *

Monday 13.30 - 17.30

Monday 17.30 - 21.30

Thursday 17.30 - 21.30

Bursary

Please indicate here if you wish to apply for a bursary place. Please only apply for a bursary place if you are experiencing financial hardship. You will not be required to submit any financial information. Please note that bursary places are limited and will be allocated on a first come first served basis.

I wish to apply for a bursary

Signed *

Learner Agreement: Level 3 involves students learning about themselves and their colleagues as well as working with their peers developing their counselling skills. It is vital that students are able to reflect on their own patterns of relating. It is also expected that students are capable of supporting their own learning and study during the course. Please refer to terms and conditions on the website. By filling out this form you agree that you have read and understood the above statement. If accepted onto the course you must commit to completing payment as agreed. You understand that once the course has started , full or partial refunds will not be given if you decide to leave. The Banbury Counselling Academy will only offer a refund if an official complaint has been made and upheld by the CPCAB.

First Name

Last Name