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Centre for Health Education
Course Application Form

(All * marks are mandatory)

 
 


Full name (this is how you wish your name to appear on your course certificate)

Title *
Forename(s) *
Surname *


Name that you are known/called by (this will go on your ID Badge)

Name *


Personal Details

Address Line 1 *
Address Line 2
Address Line 3
Town / City *
Postcode *
Country *
Mobile Number *
Work Number
Ext-Bleep Ext: Bleep:
Email *
Special Physical Needs * [Type No, if you have no special needs]
Special Dietary Needs * [i.e. Gluten free, Any allergy, Halal, No Beef, No Pork etc.
Type No, if you have no special dietary
needs]
[Dietary needs only applicable in face to face courses.]


Professional Details

(please choose Not Applicable for any section that is not appropriate for you)

Job Title *
Speciality *
GMC/NMC/HPC Number
(UK applicants only) *
[Type N/A if you don't have any of these number]
Which NHS Health Board or NHS Trust do you work in?*
Name of Hospital or Institution *
Address of Hospital or Institution *
Address Line 1*
Address Line 2
Address Line 3
Town/City*
Country*
Postcode*


Username/Password (For Member Login)

Email(same as above)*
Password * [Minimum character 8, maximum 12, NO special character (&,!,$,%,...) Please]


Photo Upload (For Course Administration)

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.]


Course Details

Please select your course
Your selected session

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" size="50">


Potential Instructorship

If you do well at the course, would you like to be considered for instructorship?


Course Payment

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.

View our Privacy Policy*
*(Click to Download)

(Click to confirm you have read the Privacy Policy)

View our Terms & Conditions*
*(Click to Download)

(Click to confirm you have read the Terms and Conditions)

 

PLEASE NOTE: YOU WILL ONLY BE ABLE TO ACCESS YOUR ACCOUNT ONCE YOUR APPLICATION HAS BEEN APPROVED.