1A Henrietta Place

London W1G 0LZ

0207 549 1400

CAREERS IN THE COMMUNITY GRANT

Application form

Check list: Please tick below to indicate you have collated all the relevant documents required.

Application form
Manager’s support letter
Details and evidence of course
Amount of funding sought / £

Patron: Her Majesty The Queen

Kate Billingham CBE, Chair. Crystal Oldman, Chief Executive

Registered charity number 213128 Founded 1887
CAREERS IN THE COMMUNITY GRANT

Name of applicant
DOB:
Address for correpondence
Telephone number / Mobile
Email
Dependent children/adults
Name and address of current employer
Current job title:
NMC Registration number and renewal date:
Are you a Queen’s Nurse?
Have you received educational funding from the QNI in the past? (Grants from QNI can only be paid once).
Yes/No
Date received:
Current salary grade:
Does your employer support this course?
(If so, are they contributing towards the cost? Amount of contribution?)
**A letter from your manager in support of your application is required.
Please identify the course/training programme that you wish to undertake:
Course Provider:
Course validation:
NMC :
Education for Health:
Open University:
Other : please state
Cost of course:
When does payment need to be made:
(Cheques are made payable to course provider)
Course commencement date:
Course finish date:
Are you receiving abursary or any funding from elsewhere towards this course?
Please list.
Please provide a short summary of your nursing career to date (CVs will not be accepted)
Employment history/Details of your current role /qualifications professional development activities (use additional sheet if required)
How will this course help you to improve the care of your patients?
(OR prepare you for a career in the community?)
What are your career aspirations? What post would you like to have in 2 years’ time?
How did you hear of The Queen’s Nursing Institute?
Signature of applicant:

Data protection:

Your privacy is important to us, and we will NOT pass your details to any third party. The Queen's Nursing Institute will use the information provided on the application form to process the proposal and manage any funding awarded. We will also use the information to communicate with you on issues which we feel may be of interest to you. By providing us with your information, you consent to us using it for the purposes outlined above.

THE QUEEN’S NURSING INSTITUTE

EDUCATION - Monitoring Form

CONFIDENTIAL

This form is used to gather information for the purposes of monitoring adherence to our equal opportunities policy only. Information will not be used for any other purpose.

Personal data
Please indicate your age group: / 16-18 / 19-20 / 21-24 / 24-59 / 60+
Decline to say
Are you / Male / Female
Disability
Do you consider yourself to have a disability? / YES/NO / Decline to say
Ethnicity
White / Mixed
British / White and Black Caribbean
Irish / White and Black African
Any other white background / White and Asian
Any other mixed background
Asian or Asian British / Black or Black British
Indian / Caribbean
Pakistani / African
Bangladeshi / Any other Black background
Any other Asian background
Chinese or other ethnic group / Any other
Declined to say

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