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Full name (this is how you wish your name to appear on your course certificate)
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| Title * |
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| Forename(s) * |
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| Surname * |
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Name that you are known/called by (this will go on your ID Badge)
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| Name * |
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Personal Details
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| Address Line 1 * |
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| Address Line 2 |
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| Address Line 3 |
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| Town / City * |
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| Postcode * |
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| Country * |
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| Mobile Number * |
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| Work Number |
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| Ext-Bleep |
Ext:
Bleep:
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| Email * |
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| Special Physical Needs * [Type No, if you have no special needs] |
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Special Dietary Needs * [i.e. Gluten free, Any allergy, Halal, No Beef, No Pork etc.
Type No, if you have no special dietary needs] |
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Professional Details
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| Job Title * |
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[If other, please specify]
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| Speciality * |
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[If other, please specify]
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GMC/NMC/HPC Number
(UK applicants only) *
[Type N/A if you are not UK Applicant] |
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| Which NHS Health Board or NHS Trust do you work in?* |
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| Name of Hospital or Institution * |
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| Address of Hospital or Institution * |
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Username/Password (For Member Login)
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| Username * [This must contain a combination of letters and at least one number (0-9)] |
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| Password * [Minimum character 8, maximum 12, NO special character (&,!,$,%,...) Please] |
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Photo Upload (For Course Administration)
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Please upload a recent photo of yourself. *
[Please ensure that the photo you are uploading is named in the following format: 'firstname_surname', e.g. if your name is David Jones then name your photo file as David_Jones.jpg, before uploading it. We accept photo files of any of the following formats: gif, jpeg, jpg, pjpeg, x-png, png.] |
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Course Details
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| Please select your course |
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| Your selected session |
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Potential Instructorship
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| If you do well at the course, would you like to be considered for instructorship? |
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Course Payment
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| Are you paying your course fee/administration fee by yourself or is any other trust/organization paying on your behalf? [If you are normally funded by your Health Board, you will need to initially pay the fee yourself, then re-claim the cost from the Health-Board] |
Please specify:
(e.g. Self / Health Board etc..)
Disclaimer: Any interaction with your Health Board or responsibility for claiming funding support lies solely with you, the candidate, and not with the course organiser. |
Privacy & Policy Accepted*
(See our privacy and policy document) |
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| Terms & Conditions Accepted* |
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