Centre for Health Education
Instructor Registration

(All * fields 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 *
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]


Professional Details
Job Title *
Speciality *
GMC/NMC/HPC Number
(UK applicants only) *
[Type N/A if you are not UK Applicant]
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 *
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.]

 

Teaching Details
Which course(s) are you applying to teach on?
[APLS/e-ALS/ALS/GIC etc]
Please choose all types of courses that you wish to teach...
APLS
PHPLS
EPALS
ALS
e-ALS
GIC
ILS
e-ILS
NLS
PLAB1
PLAB2


In relation to this course type, please complete the table below to outline your teaching history (Please type N/A in the fields that are not applicable for you. For example if you are IC1 and haven't done IC2 then please write N/A in the fields relevant to IC2 and FI)

Status/Course Details Course Date (dd/mm/yyyy) Course Centre
Instructor Potential (IP) * Please state when & where you were nominated for IP status.
Generic Instructor Course (GIC) * Please state when/where you undertook GIC training.
Instructor Candidate Level 1 (IC1) * Please state when/where you did your first IC course
Instructor Candidate Level 2 (IC2) * Please state when/where you did your second IC course (If you were exempt, simply write 'Exempt')
Full Instructor (FI) * Please state when/where you taught on a course as a FI for the first time.
Full Instructor (FI) * Please state when you last taught as a full instructor

 

 

Teaching Credentials

Type of Course

Course Title

Instructor Status

Paediatrics & Neonatology *

EPALS

APLS

PHPLS

pILS

PLS

EMNCH

ECHT

VHW

NLS

NCC

Obstetrics *

MOET

POET

TBA

Acute Medicine/Surgery *

ALS

ILS

MedicALS

ATLS

ETC

Incident Management *

MIMMS

HMIMMS

HAZIMMS

Child Protection *

CPRR

CPIP

Transfer Medicine *

STaR

NaPSTaR

Teaching Skills *

GIC

HF

 

Accomodation
Do you need an accomodation for the course that you wish to teach on? Please select an appropriate option for you.

 

Parking
Do you want to arrange car parking?

If you require us to book parking for you, please state your car registration number and the dates of your car check-in and check-out.
Car Registration no.

 

 

Professional Time
Are you teaching on this course during your personal time or professional time?
Please check all the details and click on the check box before submitting the application form.* Please make a selection.