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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]
[Dietary needs only applicable in face to face courses.] |
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Professional Details
(please choose Not Applicable for any section that is not appropriate for you)
|
| Job Title * |
|
|
[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 don't have any of these number] |
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| Which NHS Health Board or NHS Trust do you work in?* |
|
| Name of Hospital or Institution * |
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| Address of Hospital or Institution * |
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Create Username/Password (For Member Login)
USERNAME is Email address and password is you need to create one.
|
| Email(same as above)* |
|
| Password * [Minimum character 8, maximum 12, NO special character (&,!,$,%,...) Please] |
|
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
|
| Please select your course |
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| 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? |
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|
| |
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