Counselling CoursesOnline Application Form Please review the guidance notes and complete the installment form (if necessary) shown on this page before submitting this application form. Applications are subject to approval and evidence of prior levels are required (except for the introduction course)Please enable JavaScript in your browser to complete this form.You are applying for the following courseTitle *MrMrsMissMsMxPrefer not to sayPlease select your preferred title from the drop-down listGenderMaleFemalePrefer not to sayDate of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name *FirstLastPlease enter your first name and your last name(s) in the boxes exactly as they are stated on official documents, such as your passport, birth certificate or driving licence. If your name is too long for the available space please enter it in full at the beginning of your personal statement.Preferred first name Previous surname at 16th birthdayAddress 1 *Address 2 *Post code *Parish *St HelierGrouvilleSt BréladeSt ClementSt JohnSt LawrenceSt MartinSt MarySt OuenSt PeterSt SaviourTrinityHome telephone numberPlease enter your main contact numberMobile number *Please enter your mobile numberEmail address *EmailConfirm EmailLocal emergency contact *NameLocal emergency contact number *Emergency contact numberNationality *JerseyBritishIrishPolishPortugueseRomanianOtherYour nationality should be stated in your passportCriminal convictions *YesNoIf you have any criminal convictions please select Yes; otherwise select No. If you select Yes you will not be automatically excluded from the application process. Refer to the guidance notes for a full explanation. Disability / special needs *• No disability• You have a social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder• You are blind or have a serious visual impairment uncorrected by glasses• You are deaf or have a serious hearing impairment• You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy• You have a mental health condition, such as depression, schizophrenia or anxiety disorder• You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D• You have physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches• You have a disability, impairment or medical condition that is not listed above• You have two or more impairments and/or disabling medical conditionsIf you have a disability, special needs (including dyslexia or another specific learning difficulty) or a medical condition, please select the most appropriate option from the list.Disability - additional informationIf you feel you may have a disability, special needs or a medical condition that has not yet been medically diagnosed you should give further details of the circumstances in this free text box .Is English your first language *YesNoPlease let us know your first language. *What is your ethnic group *Asian or Asian BritishBlack, African, Black British or CaribbeanMixed or multiple ethnic groupsWhiteAnother ethnic groupPrefer not to sayPlease select from the drop-down list the category which most closely describes your ethnic origin. If you do not wish to provide this information, please select prefer not to say.White ethnicity sub categories31 English / Welsh / Scottish / Northern Irish / British32 Irish33 Gypsy or Irish Traveller34 Any Other White backgroundAsian ethnicity sub categories39 Indian40 Pakistani41 Bangladeshi42 Chinese43 Any other Asian backgroundBlack ethnicity sub categories44 African45 Caribbean46 Any other Black / African / Caribbean backgroundAnother ethnicity sub categories47 Arab98 Any other ethnic group99 Not providedMixed / multiple ethnicity sub categories35 White and Black Caribbean36 White and Black African37 White and Asian38 Any Other Mixed / multiple ethnic backgroundReligion or belief *No religion or beliefChristian (all denominations)BuddhistHinduJewishMuslimSikhAny other religion or beliefPrefer not to sayIf you do not wish to provide the information, please select prefer not to say.Sexual orientation *BisexualGay manGay woman / LesbianHeterosexual / StraightOtherPrefer not to sayIf you sexual orientation is not included in the list select Other.Do you identify as transgender *YesNoPrefer not to sayPersonal statement *Academic qualifications *Relevant experienceDeclaration *YesI confirm that the information given on this application is true, complete and accurate. No information requested or other material has been omitted. By submitting this form I agree to the following. I need a minimum attendance of 80% to gain the qualification. Should my attendance fall below 80%, I may not be able to complete the qualification. I am not experiencing any severe emotional difficulty that may affect my participation on this course. If I leave the course, I understand that no refund or transfer will be offered by the college. Who will be paying for this course *SelfEmployer3rd partyLayoutEmployer / 3rd party details *Company nameEmployer / 3rd Party email address *Who should we contact to confirm payment detailsEmployer / 3rd party address 1 *Employer / 3rd party address 2 *Contact number *You employer or 3rd party will be contacted for payment prior to you being enrolled on the course.Post code *Parish *St HelierGrouvilleSt BréladeSt ClementSt JohnSt LawrenceSt MartinSt MarySt OuenSt PeterSt SaviourTrinityHow will the course be paid for *Single payment3 Instalments (or less)Monthly payment schemeInstalment plan agreement *I Agree that I have read and understood the followingI wish to pay the fees by instalments and understand that all fees must be settled 4 weeks prior to the final session of the course. The total cost of the fees are still due to the college should I withdraw from the course. I agree to pay an administration charge of £15 or 2% of the total course fee, whichever is higher. This will be added if paying by more than 3 instalments (maximum number of instalments is 10). To the best of my knowledge I have no outstanding debts with Highlands College, or any of its entities. I accept that my instalment plan and place on the course may be withdrawn if this is found to be untrue. Someone from the Finance team at Highlands will be in touch regarding payment for the courseWebsiteSubmit Payment option If you require a payment plan please print off and fill in this Instalment form
