Milton Keynes Bereavement Service

 

 

 

Application Form for Introduction to Bereavement Counselling Course

 

 

Full name:

 

Mr. Mrs. Ms. Miss.                                                                                Age:

Address:

 

 

 

 

Telephone nos.:  home:

                           work:

                           mobile:

 

email address:        

CRB Number :                                           Agency who make the application:

 

Start Date:                                                Renewal Date:

 

Any special needs in terms of access, etc?

 

Mode of Transport?

 

Occupation:

 

State your reasons for applying for this Course

 

 

 

If wishing to be considered to become a volunteer with the Milton Keynes Bereavement Service, please briefly state your reasons why.

 

 

 

 

 

Please give brief details and dates of any major losses in your life

 

 

 

 

 

 

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Relevant Course attended if any:

 

 

 

 

 

 

 

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Please state times when you would be available for interview:-

 

 

 

 

 

 

THOSE WISHING TO BE CONSIDERED TO BECOME A VOLUNTEER PLEASE GIVE NAMES, ADDRESSES, OCCUPATIONS, LENGTH OF ACQUAINTANCESHIP OF TWO PEOPLE WHO KNOW YOU WELL, BUT ARE NOT RELATED TO YOU, TO WHOM REFERENCE CAN BE MADE:

 

Name:                                                               Name:

 

Address:                                                           Address:

 

 

 

 

 

 

Email Address:                                             Email Address:

Telephone no:                                                Telephone no:

 

Occupation:                                                     Occupation:

 

How long known:                                            How long known:

 

 

 

 

 

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