Registration Form Counselling 2009

PENANG COUNSELLING GROUP Sponsors: The Befrienders Penang; Family Planning Association Penang; The National Cancer Society of Malaysia, Penang Branch; Women’s Centre for Change; Women’s Welfare Council, Penang and Young Women’s Christian Association of Penang

COUNSELLING COURSE 2009

PARTICIPANTS’ REQUIREMENTS •

Any person who is interested in acquiring basic counselling skills.

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Course participants have to be proficient in English as course instructions, notes and reading assignments as well as stipulated written reports and examination will be in English.

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Participants from NGOs have to be nominated by their respective organisations.

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As the maximum number of participants that can be accepted is 25, please register early. Places will be on a first come first served basis.

Course Fees: The course fee is RM250.00. We look forward to your support and participation. Thank you. For further enquiries, please contact:

PENANG COUNSELLING GROUP c/o National Cancer Society of Malaysia, (Penang Branch) 250A Jalan Air Itam 10460 Penang Tel: 04-228 4140 Fax: 04-226 4676 Email: [email protected] / [email protected]

PENANG COUNSELLING GROUP

COUNSELLING COURSE 2009

REGISTRATION FORM For office use:

Application No:..................................... Receipt No:.............................

Payment Cash/Cheque ………………………………..………………... Date accepted:........................

A.

PERSONAL DETAILS

Name:

I/C No: (Old)

Sex:

I/C No: (New)

-

Male

/ Female

-

Date of Birth:

Profession: Day

Month

Year

Organisation: Position in Organisation: Home Address: Post code:

State:

Post code:

State:

Business Address:

Tel No.:

(O)

(H)

Fax No.:

B. VIEWPOINTS Please give your reasons for wishing to join this course and what you hope to gain from it.

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Please indicate any activities of voluntary work you have undertaken in the field of counselling:

If your answer to the above is “NONE”, will you consider volunteering your services as a lay counsellor after successfully taking the course? YES / NO Please give reasons for your answer:

Please describe your organisation in terms of nature, number of employees and need for lay counsellors:

Please note: Written answers to all of the questions may be made on separate sheet(s) of paper if space provided for them are insufficient. Thank you.

C.

REGISTRATION / PAYMENT

Please submit this Form together with your payment either by cheque or bank draft crossed and made payable to the “National Cancer Society of Malaysia, Penang Branch” and send to: The Secretariat, Counselling Course 2009 c/o National Cancer Society of Malaysia, Penang Branch 250A Jalan Air Itam 10460 Penang

Registration for course participants will close on: 7 June 2009

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