S A Council for Social Service Professions (SACSSP)

S A Council for Social Service Professions
(SACSSP)
Private Bag X12, Gezina, 0031
Tel: (012) 356 8300
Email: mall@sacssp.co.za
lnq:
37 Annie Botha Ave, Pretoria, 0084
Fax :( 012) 356 8400
Website: www.sacssp.co.za
Ref:
APPLICATION FOR REGISTRATION AS
A CHILD AND YOUTH CARE WORKER
THIS APPLICATION FORM MUST BE COMPLETED IN PRINT OR TYPING BY CHILD AND YOUTH CARE
WORKERS (CYCW) ONLY
Study the CYCW application form carefully before completing it. Answer all questions fully, clearly and co rre ct l y.
Questions, which do not apply to you, must be clearly deleted. Should you have to make any corrections to your answers,
initial them in the margin.
PLEASE NOTE: To avoid delay of your registration, your proof of payment and documents as prescribed on page
one and two MUST accompany this application form.
1.
PERSONAL PARTICULARS: THIS SECTION IS COMPULSORY TO ALL
1.1
1.2
1.3
Title
Prof.
Dr.
Revd
.
Mr
Miss
Ms.
Surname
Previous
Surname
1.4
Full
Names
1.5
Registration number as student Child and Youth Care Worker
For office use only
2.
Mrs.
-
7
0
-
PLEASE NOTE: This application must be accompanied by the following:
2.1 If applying for registration as a CYCW at the Professional level complete Section A, if applying for
registration at Professional level with a level 7 qualification in the Humanities or Social Sciences
complete Section A and B and if applying for registration as a CYCW at Auxiliary level complete
Section C
2.2
A completed assessment document of Proof of Evidence (PoE) at level 8, if applying for Registration as professional
CYCW or PoE at level 4 if applying for registration as an Auxiliary CYCW and is required in terms of the Regulations
for Registration.
2.3
A Certified copy of documentary proof of your names, identity document / residence permit number and date of
birth / acceptable to the Council.
2.4
A certified copy of documentary proof of the qualification(s) on the basis of which you apply for registration
as a CYCW.
1
2.5
Original (NOT copy) of documentary proof issued by the training institution in which is listed:
2.5.1 ALL the subjects you have passed during all years of study and the duration of the course in each subject.
2.5.2 ALL the subjects/modules credited or exempted having been obtained from another university of
the learning programme over a period of study years.
2.6 If your qualification(s) was/were obtained outside the R SA, also original copy of:
2.6.1 documentary proof from t h e training institution where you received tuition and training in Child and
Youth Care Work of the content of theoretical tuition and both the nature and duration of field
instruction you received in each subject;
2.6.2 documentary proof t h a t the training institution where you received tuition and training in Child and Youth
Care Work is accredited, specifying the body with which the training institution is accredited the training
institution is not a c c r e d i t e d , proof of any other form of recognition that the training institution has;
2.6.3
in the case of a training institution that is accredited, documentary proof from the accrediting body that
the qualification(s) is/are or was/were the a c c e pt ed tuition and training for Child and Youth Care Work
in the count r y concerned.
2.7 The Council may order that a portfolio be submitted and an assessment interview be conducted with
applicants who obtained their qualification(s) in a country outside the R SA.
2.8 All documents accompanying this application that are not drawn up in English, must be accompanied
by a translation prepared by a sworn translator in English, as well as a certified copy of the original
document, and the onus shall be on the applicant to have such document so translated.
2.9
3.
A copy of the BANK DEPOSIT SLIP or proof o f an ELECTRONIC/ INTERNET TRANSFER as proof of payment to the
value of the prescribed registration fee.
POST your application using registered mail to the R e gi s t r a r , SA Council for Social Service Professions,
Private Bag Xl2, Gezina,0031.
4.
REGISTRATION PARTICULARS
4.1
Have you previously applied for registration as a Child and Youth Care Worker / Student Child and Youth
Care Worker in RSA?
Yes
4.2
No
If yes, was the application? Approved
Rejected
If application was rejected, please provide reason/s:
4.3
4.4
Registration number as a Child and Youth
Care Worker (For office use)
Registration date
(For office use only)
Y
70
M
D
-
4.5
M
-
D
-
Identity or residence
permit number
Y
4.7
-
If you applied for restoration, state the date on which your name was removed from the Register:
Y
4.6
-
M
D
Date of birth:
(Attach a certified copy of acceptable documentary proof of your names, identity or residence permit number)
2
1. Male
2. Female
Population
Group
1. White
2. Coloured
Marital Status
1. Never Married
4.8
Gender
4.9
4.10
4.11
3.Black
2. Married
4.Indian
3. Divorced
5.other
4. Widow/Widower
Residential address:
Postal Code
Tel no …… (code )………… (number): ................................. Cell ………………………
Email address, if any: ...............................................................................................................
4.12
Postal address:
Postal Code
3
5.
EMPLOYMENT PARTICULARS
PLEASE NOTE that application will NOT be completed without you filling in the full employment details below:
5.1
Period of employment as Child and Youth Care Work er with PREVIOUS EMPLOYER:
From
To
Name and address of PREVIOUS EMPLOYER:
Postal Code
Tel No (code and number):
5.2
Fax Number:
Email Address:
Date of commencement of employment with PRESENT EMPLOYER:
Y
D
M
-
-
Name and address of PRESENT EMPLOYER:
Postal Code
Tel No (code and number):
Fax number:
Present post designation:
NATURE OF PRESENT CHILD AND YOUTH CARE WORK EMPLOYER :
State Dept
Local Government
NGO/NPO/CBO
Industry
Private Practice
Other
4
Does not
practise
Unemployed
cycw
6.
Pensioner
Over 65yrears
Living
abroad
TRAINING INSTITUTION WHERE YOU OBTAINED YOUR BASIC (PRE-REGISTRATION)
QUALIFICATION(S) IN CHILD AND YOUTH CARE WORK
6.1
Training institution in the R.S.A.:
6.1.1
TRAINING OF INSTITUTION____________
6.1.2 Other:
6.2
Training institution outside the R.S.A.:
6.2.1 Country
6.2.2 University/College
SECTION A
TO BE COMPLETED IF APPYING FOR REGISTRATION AT THE PROFESSIONAL LEVEL
ACADEMIC PARTICULARS OF BASIC (PRE-REGISTRATION)QUALIFICATIONS(S)IN
CHILD AND YOUTH CARE WORK
7.
7.1 Q u a l i f i c a t i o n
7.1 .1 Duration of course
7.2
2. Diploma
1. Degree
3 years
Other
4 years
Date on which you initially registered as a student for this qualification:
Y
D
M
-
-
7.2 .1 Name of Qualification
E.g B Tech CYCW
Higher Level
Level 6
Level 7
Level 8
7.2 .2 NQF level of qualification in CYCW
7.2 .3 Post graduation qualification
5
7.3 COMPLETE SUBJECT /MODULE IN RESPECT OF YOUR CYCW QUALIFICATION.
NAME OF SUBJECT:
YEAR LEVEL:
1
NAME OF MODULE/SUBJECT
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
YEAR LEVEL:
2
_
NAME OF MODULE/ SUBJECT
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
YEAR LEVEL:
3
_
NAME OF MODULE/ SUBJECT
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
NAME OF MODULE/ SUBJECT
YEAR LEVEL:
4
_
CODE
1.
2.
3.
4.
5.
NOTE: Attach completed Portfolio of Evidence (PoE) assessment at level 8, if your qualification
is NQF level 6 or 7.
6
SECTION B
7.4 TO BE COMPLETED BY APPLICANTS WITH QUALIFICATION IN HUMANITIES
NAME OF SUBJECT:
YEAR LEVEL:
1
NAME OF MODULE/ SUBJECT
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
YEAR LEVEL:
2
NAME OF MODULE/ SUBJECT
_
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
YEAR LEVEL:
3
NAME OF MODULE/ SUBJECT
_
CODE
1.
2.
3.
4.
5.
NAME OF SUBJECT:
YEAR LEVEL:
NAME OF MODULE/ SUBJECT
4
_
CODE
1.
2.
3.
4.
5.
7.5 NAME OF COMPLETED HIGHEST QUALIFICATION IN HUMANITIES OR SOCIAL SCIENCES
7.6
Name of University and Department in which obtained.
Department _________________________
University __________________________
7.7 Year Obtained___________________
7.8
Post -graduation qualification
7
SECTION C( I)
8. TO BE COMPLETED BY CYCW APPLYING FOR REGISTRATION AT AUXILIARY LEVEL
WITH A COMPLETED FETC IN CYC.
8.1 CHILD AND YOUTH CARE WORK MODULES/ SUBJECTS ONLY*
8.1.1 CHILD AND YOUTH CARE WORK MODULES- YEAR LEVEL-l
NAME OF MODULE
CODE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
8.1.2 CHILD AND YOUTH CARE WORK MODULES/SUBJECTS YEAR LEVEL-2
NAME OF MODULE
CODE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
8.1.3 CHILD AND YOUTH CARE WORK M O D U L E S / SUBJECTS YEAR LEVEL-3
NAME OF MODULE
CODE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
8.1.4 CHILD AND YOUTH CARE WORK MODULES/SUBJECTS YEAR LEVEL-4 AND ABOVE
NAME OF MODULE
CODE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
8.1.5 Date of completion of FETC CYC:
Y-
M-
D
8
SECTION C (II)
8.2 COMPLETE THIS SECTION ONLY IF YOU DO NOT HAVE A COMPLETED FETC QUALIFICATION
BUT HAVE COMPLETED 1650 HOURS OF THEORETICAL AND PRACTICAL LEARNING
COURSE/ WORSHOP /TRAINING
8.3
HOURS
NOTE: THIS SECTION IS COMPULSORY TO ALL
8.3.1. Proof of evidence of the above course/workshops /training must be attached to this document
8.3.2 Completed proof of evidence Assessment (PoE) must be attached to this application.
SECTION C( III)
8.4.
Applicants for registration at the Auxiliary level and who are presently employed as a Child and Youth
Care Worker and is applying on the understanding that CYC registration will be permitted for a period
of 3 (three) years only must submit proof of the following:8.4.1 Proof of present employment as a Child and Youth Care Worker must be attached
8.4.2 Your job description signed as the work that you are required to do, by the Director/Manager of
the organization in which you are presently employed. This must be attached to this application.
9
9.1
Have you ever been found guilty of unprofessional or improper conduct by the Council?
9.2
If yes-
9.2.1
were you reprimanded or cautioned?
9.2.2
was your registration suspended?
9.2.3
was your registration cancelled?
9.2.4
was the imposition of a penalty postponed?
9.2.5
was the execution of your p e n a l t y suspended?
9.3
Have you ever been found guilty of an offence by a court of law?
9.
GENERAL
QUESTIONS
If yes, specify the nature of the offence of which you were convicted, the year in which it
took place and the sentence passed
( a ) Nature of offence:
9.4
( b ) Year of offence:
( c ) Sentence passed:
9.5
Are there any legal steps pending against you at present?
9.6
If yes, specify what steps:
9.7
Have requested clearance from the Child protection register
Yes No
Yes No
10
10
DECLARATION
I, the undersigned, declare that the information furnished in this application form is true and correct in all
respects and that I am unaware of anything which would serve as an impediment to the registration of
my name as a Child and Youth Care Worker.
Signed at ………………………………………………………… this ………………….day
of………………………………. 20………………………………
SIGNATURE OF APPLICANT
11