COLLEGE OF PEDIATRIC CRITICAL CARE

Indian Diploma in Pediatric Critical Care Medicine

( Application Form- One Year Course)

(Form to be type written) (Read instruction before filling)

(A)
NAME:
Date of birth
Address for all correspondence till exam:
City: / Pin Code
E mail / Tel Land line
Cell
(B)
Qualifications / Year of passing / Attempt / University
MBBS
MD (Peds)
DCH
DNB (Peds)
Others
(C)
Present Employment
(D)
Experience after internship: (Residency training, work experience etc. with dates)
1)
2)
3)
4)
(E)
Which Other course you have registered concurrently along with this diploma?
Name of the course ______
Joining date ______Date of expected ______
Which Other course you will be registering for (planning for) in next 12 months ?
______
(F)
Name and Address of the Hospital from where you are applying ?
______
Name and signature of the program director agreeing to accept the candidate for training….
Director Name ______Sign _ _ _
Date of joining: _ _ (dt) _ _ _(mo) _ _ _ (Yr)
I agree to abide by the rules and regulations of the Academic Council.

Signed by the candidate

Please read the following instruction carefully:

1)This form is for 1 year Fellowship Course by College Of Pediatric Critical Care.

2)The form must be typed, printed and then sent as a hard copy duly signed by the candidate and the program director to the address below. One soft copy (with soft copy of photo should also be sent as an attachment to email given below)

3)Only candidates who have completed their MD/DNB / DCH in Pediatrics (MCI recognized) are eligible.Curriculum duration for DCH candidates is 24 months and MD/ DNB is for 12 months.

4)Fellowship for 2018 academic year will begin on Feb. 1st 2018. Admission to fellowship can be given strictly only till 30th Jan 2018.

5)The final examination for these candidates admitted as per rules will be held after 12 months of joining fellowship.

6)There will be an application / registration fee of Rs. 15,000/- payable by DD payable at Gurgaonmade out to‘College of Pediatric Critical Care. Draft is to be enclosed with this application form. Application fee is non refundable.

7)The candidate will abide by the curriculum as prescribed in the manual of the College of Pediatric Critical Care.

8)The candidate will abide by the rules and regulations of the institution of registration.

9)The remuneration to the candidate will be according to the rules of the institution. The College of Pediatric Critical Care does not take responsibility for any monetary compensation.

10)The candidate will be responsible for any expenses towards examination fees fixed by the College of Pediatric Critical Care.

11)The candidate will produce a certificate of satisfactory residency from the program director before being allowed to appear for the qualifying examination.

12)Examination form will be mailed to all the candidates through program directors approximately 2 months before the final examination and fees will be Rs. 15000/-.

Please go through all the details of the curriculum and course requirements. These are available from your registering institution.

Please send the Demand Draft (DD) by courier to..

Dr. Praveen Khilnani

Chancellor, College of Pediatric Critical Care

Clinical Director,

Madhukar Rainbow Children’s Hospital,

FC-29, Plot No. 5, Geetanjali Near Malviya Nagar Metro Station,

Gate No.1, New Delhi-110017.

Email: and

Additional Important Instructions:

(1)Memebrship of some organizations is very important for all those who apply for this fellowship. Therefor obtain membership for …

a)ISCCM mandatory and membership number is to be submitted to the college within 6 months of this enrollment.

b)Membership of is also mandatory and to be submitted to the college within 6 months of this enrollment.

(2)A publication has been made compulsory for this fellowship and its work needs to be completed three months prior to final examination. Directors will instruct you in detail regarding this.

(3)E-log has to be filled in by the candidates on periodic basis. The details of this will be mailed to you by the college office.

______

Sign of Candidate (Date)

______

Sign of Director (Date)

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