Application for Additional Funding to Support Maternity, Paternity and Adoption Leave

When completing this form please refer to the guidance notes supplied.

This form should be completed first by the relevant Education Provider, within 5 working days of receiving the request from the student/trainee and then where applicable by the employing Healthcare Service Provider within 5 working days of receiving the application form from the Education Provider (NOT the student/trainee requiring the additional funding).

All sections of the form must be completed and submitted electronically. Incomplete application forms will not be considered by the panel and will be returned to the Education Provider.

Section A – Student Information
Student Category (Please tick )
1. / Pre-registration Student
(to be completed by Education Provider only) / 2. / Sponsored Student
(to be completed by Education Provider & Employing Healthcare Service Provider)
3. / Employed Trainee
(to be completed by Education Provider & Employing Healthcare Service Provider) / 4. / Placement Student
(to be completed by Education Provider & Employing Healthcare Service Provider)
Student/Trainee Details:
Full Name
Student Number
Programme of Study
Original Cohort / Month / Year
Section B – Education Provider/Employer Details
Name of Education Provider
Name of Employing Healthcare Service Provider
Section C – Maternity, Paternity or Adoption Leave Details
Expected Start Date / (dd/mm/yyyy) / Expected End Date / (dd/mm/yyyy)
For maternity, have you seen a copy of the students/trainees Maternity Certificate (MAT B1 form) / Yes / No
Will the student/trainee return to the original cohort? / Yes / No
If no, which cohort will they join? (Month/Year) / Month / Year
Section D – Details of Funding Required
What additional funding is required? (Please tick  all that are appropriate and include the amount of funding required)
Description / Tick
 / Time Period (Months) / Funding Required (£’s)
Tuition fees (including exam fees)
Bursary (amount to be determined by NHS Student Bursaries)
Salary Support
Other Support
Total Funding Required / £ 0.00
Section E – Additional Information
In the box below, please provide any additional information if required:
Section F – Authorisation
Authorised by: / Print Name / E-mail Address / Date
Education Provider
Head of Programme/Lead
Employing Healthcare Service Provider
Education Coordinator/Lead
FOR OFFICE USE ONLY
Date Received: / Date Returned:
Name of Education Provider Lead Notified: / Name of Employer Lead Notified:
Request Approved: / Yes/No
Details of Panel Decision:
Confirmed Approved Requirements:
Comments/Action Plan: / N/A

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