UNIVERSITYDENTALHOSPITAL OF MANCHESTER
CentralManchesterSchool for Dental Care Professionals
Post Registration Courses - APPLICATION FORM
Please complete this form in BLOCK CAPITALS to: - Mrs Ann Jones, Education & Development Manager,The Central Manchester School for Dental Care Professionals, 3rd Floor, Staff-Side, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH.
Tel: 0161 2725670 / Fax: 0161 272 5686 / Email:
Please note; Course places are limited and will be offered on a ‘first-come first-served’ basis.
NAME OF COURSE (Please Circle)
DENTAL SEDATION ORAL HEALTH EDUCATION ORTHODONTIC NURSING
Course Start Date: - …………………………………………………………………………………………
PERSONAL DETAILS
Surname
First name(s)
Postal Address
Post Code:GDC Registration Number:
Daytime Telephone number (including STD code): Mobile Telephone Number:
Email address:
PRACTICE DETAILS
Practice Name & Address:
Post Code: Telephone Number:
Name of Supervising Dentist:
Supervising Dentist’s GDC Registration Number:
QUALIFICATIONS
Please circle the correct qualification you have achieved:-
NEBDN National Certificate/Diploma in Dental NursingNVQ/SVQ Level 3 in Oral Healthcare
Level 3 Diploma in Dental NursingHospital Certificate
Please attach photocopies of your dental nursing certificate and GDC registration certificate when submitting this application form. If your certificates are in your maiden name, then please enclosea photocopy of your marriage certificate.
PAYMENT
The full cost of the course is £750.00per candidate. NHS practices that come under the catchment areas of the Northwestern Deanery (Cumbria & Lancashire, Cheshire & Merseyside & Greater Manchester) are eligible for part funding towards the course fee. If you are eligible for a funded place,the course fee will be £250.00.
I enclose a cheque for £750.00 payable to CMFT
(please write your full name on the rear of the cheque & specify which course)
I am an NHS practice eligible for funding and I enclose a cheque for £250.00 payable to CMFT
(please write your full name on the rear of the cheque & specify which course)
Please invoice the finance department for £250.00/£750.00 (please tick and circle the correct amount)
Complete the section below:-
In cases where organisations need invoicing, please provide the full details of who to send the invoice to:
Name:
Position:
Address:
Email:
CANCELLATIONS
Cancellations received at least seven days before the course start date will be refunded, subject to a 25% administration charge. There will be no refund of course fees after this time.
DECLARATION
I agree to attend all training sessions and complete the training programme; I confirm that I am able to meet the clinical requirements for the record of experience. I agree to my employer receiving updates on my progress on the course.
Failure to complete the full course and sit the examination will result in a claw back of training fees which I agree to pay (for funded places)
Signature of applicant: ………………………………… Date: …………………………………….
GDC Registration Number …………………….
Please note; Your GDC registration may be at risk if you knowingly make a false declaration.
EMPLOYER DECLARATION
In order to achieve the award it is important to have the support from your employing dentist.
Please ask your employer to read and sign the agreement below.
I confirm that:-
- The candidate will be released from work for timetabled activity sessions.
- The candidate will be able to fulfil the clinical requirements of the record of experience
- I agree to validate the logsheets and competences for the record of experience
Employers Signature: ………………………………………………… Date: ………………………………………….
GDC Registration Number …………………………………….……….
Your GDC registration may be at risk if you knowingly make a false declaration
The CentralManchesterSchool for Dental Care Professionals has a progress monitoring policy for all students. Employers will be kept updated on the progress of the students throughout the duration of the course
CHECKLIST
Please ensure you have included the following with your application:
Completed application form
Copy of Dental Nursing Certificate
Copy of GDC Registration Certificate
Cheque to cover payment
Authorisation letter if invoice requested
Successful applicants will be required to attend an informal interview; the details of the interview will be forwarded on receipt of the application form.
Post Registration Course - APPLICATION FOR COURSE FUNDING
DESCRIBE YOUR CURRENT ROLE:
DO YOU HAVE A PERSONAL DEVELOPMENT PLAN? (Circle)
IF YOU DO NOT HAVE A PERSONAL DEVELOPMENT PLAN,
WOULD YOU LIKE A DEANERY FACILITATOR TO ASSIST
YOU TO DEVELOP A PLAN?
(Please contact Christine Sutton on 0161 625 7658 to arrange a visit)
DOES THE PRACTICE HAVE A PRACTICE DEVELOPMENT PLAN?
DESCRIBE HOW THIS TRAINING WOULD BENEFIT YOUR ROLE?
DESCRIBE HOW THIS TRAINING WOULD BENEFIT THE PRACTICE AND IMPACT ON DELIVERY OF SERVICES?
This training is part of the practice development plan and as the employer I agree to release the applicant for training
Signature ofEmployer:…………………………..……………… Date: ………………….…………………………….
I agree to attend all training sessions and complete the training programme; I understand that failure to attend all training sessions or incompletion of training may result in a claw back of training fees, which I agree to pay
Signature of applicant: ……………………………………………Date: …………………..…………………………….
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Post Registration Course Application Form