QQI Registration Form

QQI Certified Courses Booking Online Form 2021



First Name, Surname *

Mobile Phone *

Date of Birth *


Email *

Address *


QQI Level 5 Palliative Care Support (5N3769) (Day). Start Date: 06/12/2021 :

QQI Level 5 Safety and Health at Work (5N1794) (Day). Start Date: 15/12/2021 :

Back to Education Initiative, programme is starting January 2022 :

Upcoming courses in 2022:

Mondays 9:30 - 2:30

QQI Level 5 Care of Older Person (5N2706) (Day). Start Date: 31/01/2022 :

QQI Level 5 Personal and Professional Development (5N2985) (Day). Start Date: 14/04/2022 :

Wednesdays 9:30 - 2:30

QQI Level 5 Communications (5N0690) (Day). Start Date: 09/02/2022 :

QQI Level 5 Care Skills (5N2770) (Day). Start Date: 30/03/2022 :

Wednesdays 6:30 - 9:30

QQI Level 5 Care Skills (5N2770) (Evening). Start Date: 02/02/2022 :

QQI Level 5 Care of Older Person (5N2706) (Evening). Start Date: 06/04/2022 :



Medical card: Do you have a valid medical card (Yes or No) : Yes No

Please upload your valid medical card (only pdf, png, jpeg and jpg formats are accepted, max file size is 15MB):

Photo ID (can be a valid Public Service Card, a valid Driver Licence, a valid Passport or any valid document with photo, only pdf, png, jpeg and jpg formats are accepted, max file size is 15MB):

For Level 5 learners only

Have you completed a previous QQI Level 5 module? : Yes No

If the module was completed with Women's Community Projects, please skip to NEXT OF KIN DETAILS

If the module was completed outside of Women's Community Projects, please upload a copy (only pdf, png, jpeg and jpg formats are accepted!, max file size is 15MB):

• A Pre-test is required for entry to level 5 module unless the learner can produce a copy of their Irish Leaving Certificate or QQI level 4 or higher. To book an appointment for a Pre-test - please email adult.ed@wcpmullingar.ie


First Name, Surname: *

Contact details: *

Where did you hear about us?

Would you like to receive monthly emails regarding upcoming courses (Yes or No)? : Yes No

Do you have any medical or health issues that we need to be made aware of (Yes or No)? : Yes No

If yes, please comment:

Do you have any specific learning needs that tutors need to be aware of (Yes or No)? : Yes No

If yes, would you like to discuss it with us:


Please read the following information carefully before submitting this registration form. A submitted form is your understanding and agreement to the learner responsibilities shown below.

• Due to Government advice regarding COVID 19, our level 5 modules will be delivered through an online platform called Zoom, which is a free app/programme. To take part on one of these courses you should ensure that you have access to a PC/Laptop and a webcam. A mobile phone may also be required for recording assessment demonstrations.

• Basic computer skills are required to complete these courses as you will be required to download your teacher’s notes and presentations, type your assignments and email the drafts/completed assignments to your teacher for marking.

• A minimum of 80% attendance is required to complete all our QQI modules and submit assessment evidence for certification with QQI.

• Digital recording/photography – as part of your course your tutor may record the Zoom class and take photographs of the group etc. If you do not wish to be included in the photographs, please tick here

• An academic yearly €20 centre registration fee is applicable to all students.

• All module fees must be paid in full, at least five business days before the module commencement date. If your employer is paying for the course, please ask them to confirm your attendance with the office by email (adult.ed@wcpmullingar.ie).

• Fees are non-refundable unless the office is notified, through written confirmation, a minimum of 48 business hours before commencement date (email adult.ed@wcpmullingar.ie )

We fully respect your right to privacy. Any personal information which you provide to us will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Acts 1988-2018. The General Data Protection Regulation (GDPR) (EU) 2016/679 is a regulation on data protection and privacy for all individuals within the European Union.

Signature: *

Date: *