The Gibraltar School of Health Studies

APPLICATION FOR BSc Nursing (Registered Nurse: Adult Nursing)

SEPTEMBER 2017

Please complete the form in black ink and return the completed form to Human Resources, Fifth Floor, St Bernard’s Hospital, Gibraltar.

PERSONAL DETAILS

Title / Male (M) Female (F) / Date of Birth
Surname/
Family Name
First Given Name(s)
Home
Address Line 1
Address Line 2
Address Line 3
Mobile Phone No
Daytime Phone No / Home Phone No
e-mail address
(please use one box per letter or number) /

FURTHER DETAILS

Disability or Special Needs (including dyslexia) / medical condition
Yes / No
/ If yes please provide details below:

SECONDARY EDUCATION/FE/HE

/ From / To
Name and Brief address of Institution / Month / Year / Month / Year

EDUCATIONAL QUALIFICATIONS ACHIEVED / PENDING

Centre No. / Candidate No. / Month / Year / Board / Subject / Level / Result/
Grade

EMPLOYMENT HISTORY (most recent first) including any voluntary work

From / To / Full/
Part Time
Name and Address of Employer / Nature of Work / Month / Year / Month / Year

DECLARATION OF CRIMINAL RECORD

The Rehabilitation of Offenders Act

The educational programme for which you are applying is exempt from the Rehabilitation of Offenders Act. This means that you must declare any criminal convictions even if they are spent. (Please note that a conditional discharge is a conviction). You must therefore answer this question:
Have you ever had any criminal convictions?
If YES please refer to the accompanying notes / Yes / No
Do you agree to a Criminal Records check? / Yes / No

HEALTH

Please state how many days’ absence, due to illness, from employment or college you have had in the past two years?
How many periods of absence due to illness have you had in the past two years?

PERSONAL STATEMENT

Please use this space to provide us with any other details to support your application e.g. why you want to be a nurse, reasons for career change etc. Continue on a separate sheet if necessary.
DECLARATION
I confirm that the information given on this form is true, complete and accurate and no information requested or other material information has been omitted. If any information on this application form is found to be false, this may lead to the withdrawal of an offer of a place on the programme. I give my consent to the processing of my data by the School of Health Studies at St Bernard’s Hospital, Gibraltar and Kingston University. I accept that if I do not fully comply with these requirements, the School of Health Studies at St Bernard’s Hospital, Gibraltar and Kingston University shall have the right to cancel my application and I shall have no claim against the institution in relation thereto.
Under the Data Protection Act 1998, the information you supply will be held in strict confidence for the purpose of ascertaining your suitability for your chosen course of study. In the event that you become a registered student with the SHS / Kingston University your data will form the basis of your student record.
Applicant’s Signature: Date:
Please provide details of two referees. The first referee is usually someone who can comment on your academic skills. The second referee should not be a friend or relative but a professional person who knows you well enough to provide a reference, ideally an employer.
Name of first referee / Name of second referee
Post/Occupation/Relationship / Post/Occupation/Relationship
Address / Address
Tel: / Fax: / Tel: / Fax:
e-mail / e-mail
Equal Opportunity Monitoring Form

The completion of this form is voluntary, but the information it contains helps us to monitor and improve our equal opportunities policies and procedures. This sheet is removed from the application form before the short-listing process, thus ensuring that all short-listing is based on merit.

Ethnic Origin / Disability (please X any that apply)
White / No disability
Black or Black British - Caribbean / Specific learning difficulty (for example, dyslexia)
Black or Black British - African / Blind or partially sighted
Other Black Background / Deaf or hearing impairment
Asian or Asian British - Indian / Wheelchair user or mobility difficulty
Asian or Asian British - Pakistani / Personal care support
Asian or Asian British - Bangladeshi / Autistic Spectrum Disorder or Asperger Syndrome
Chinese / Mental health difficulty
Other Asian Background / Unseen disability e.g. diabetes, epilepsy
Mixed-White and Black Caribbean / Other, please specify below
Mixed-White and Black African
Mixed-White and Asian
Other Mixed Background
Arab
Gypsy/ Traveller
Other Ethnic Background
Not Known
Prefer not to say

Please note that some adjustments may only be possible if we are informed well in advance of you starting your course.

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