Programme Application Form Name *FirstLastAddress for correspondence *Phone No. *Date of Birth *Email Address *EmailConfirm EmailNationality *Gender *MaleFemaleRather not sayCustomIf "Custom", please specifySelect Module(s) *Care Support 5N0758Communications 5N0690Safety & Health at Work 5N1794Infection Prevention and Control 5N3734Work Experience 5N1356Care of the Older Person 5N2706Palliative Care Support 5N3769Person Centred Focus to Disability 5N1728Care Skills 5N2770Intellectual Disability Studies 5N1652Manual Handling and Safe Patient MovementDefibrillator TrainingAre you currently employed in healthcare? *YesNoIf so, what is your job title?How long have you been employed in this role?Do you hold a Junior Certificate or equivalent (Level 3 on the Irish NFQ)? *YesNoDo you hold a Leaving Certificate or equivalent (Level 4 on the Irish NFQ)? *YesNoPlease list your educational qualifications *(E.g. Level 5 award, Junior Certificate, Leaving Cert, etc.)Do you understand the entry requirements for this programme? *YesNoPlease confirm that you meet these entry requirements *ConfirmNot confirmIf you think you may need additional assistance to successfully complete this programme (e.g. help with reading/writing) please tick this box and we will discuss this with you on a confidential one-to-one basis *Need AssistanceDo Not Need AssistanceAre you a medical card holder? *YesNoIf yes, you are exempt from certification fees. Please furnish copy of medical card as proof of exemption. Are you in receipt of social welfare? *YesNoIf yes, you are exempt from certification fees. Please furnish copy of social welfare receipt as proof of exemption. Data Protection *I have read, understand and consentUnder the Data Protection Act 1998 and the Data (Amendment) Act 2003 and GDPR May 2018, personal information and assessment material recorded manually and electronically will be stored safely and treated as confidential by RSG Flexible Learning College. Such data will be processed fairly for specified purposes and on the basis of the consent of the person concerned or some other legitimate basis laid down by law. Full Privacy Policy visit: www.rsg.ie/privacy All learner information given on this form will be kept confidential and will only be shared for the purposes of authentication, certification and monitoring. EmailSubmit FacebookTwitterLinkedinPinterestemailPrint
