Continuing Professional Development Application Form

For office use only

Academic Decision: unconditional conditional reject comment______

Course code______instance ______Semester ______Full time / Part time ______

Signed ______Date ______

Email acknowledgement sent ______Offer letter sent______CAP letter sent ______

Deferal ______General______

______

Student ID Number______Please clearly print details using block capital letters

PERSONAL DETAILS

Surname______First Name(s)______

Title ______Previous family name______

Date of birth______MaleFemale

Home Tel No______Work Tel No______Mobile Tel No______

Email Address______

(Please PRINT your email address clearly as all correspondence will be sent electronically)

Home Address Correspondence Address

______

______

______Post Code______Post Code______

If you have previously studied at UH, it is essential to quote your student number:______

you can obtain this number by emailing your full name and date of birth to

Nationality______Country of Birth ______

Date of entry to the UK ______

Job Title ______

Professional Body Pin / Registration Number: ______

Profession (please tick one of the following)

Allied Health Professional Health Scientist Nurse

Midwife Doctor ther______

Please return completed form to:

University of Hertfordshire, CPD Health, Room 1F264, Wright Building, College Lane, Hatfield, AL10 9AB

MODULE DETAILS

Please clearly state which module(s) you would like to study in this academic year. You can obtain this information from the flyer or visit the following web address:

You can study a maximum of 45 credits on an individual basis which means you are not working towards an ward. Or if you want to work to towards an award you can study 60 credits on a part-time basis and 120 credits on a full time basis.

SEMESTER A
Course code / Title
Course code / Title
SEMESTER B
Course code / Title
Course code / Title
SEMESTER C
Course code / Title
Course code / Title

PAYMENT OF FEES

Please choose one of the following three payment options. If you do not include funding details you will be considered as self funding. Failure to complete funding information will delay the application process.

OPTION 1 – NHS CPD CONTRACT FUNDING – Money supplied to Trusts/PCTS by the SHA for training purposes

Name of Trust/PCT
Signature of Authorised Signatory
Print Name
Trust/PCT Address:
Contact number: / Email address:
Trust Code:

I confirm that the above Trust/PCT will pay the students fees for the above modules

Authoring

stamp for

CPD Contract

Funding

FEES PAYMENT CONTINUED

Option 2 – Employer/Sponsor Funding

This section must be completed if your employer or sponsor has agreed to pay all or part of your tuition fees. Student please note that without these details YOU will be liable for any outstanding fees.

Name
Address
Authorising signature
Print name
Contact number / Email address

The University charges tuition fees per course which include registration, tuition and exam fees. Fees must be paid in full once the student enrols on the programme and if he/she decides to withdraw, refunds are given in accordance with the University’s refund policy. When you sign this document you accept the terms of the University’s fees policy and agree to pay in full the amount of the tuition fees. If the student leaves your employment during the academic year you need to arrange any repayment of the fees with the student, as the University does not adjust the fees payable in this case formcompleted if an employer or sponsor has agreed to pay all or part of a student’s tuition fees

Option 3 Self funding – please tick

Please note that you will be able to pay by cash, cheque, credit or debit card on the day when you complete registration. However there is a 1.5% charge when paying by credit card.

Section 4:ACADEMIC AND EMPLOYMENT RECORD

Professional Background

Courses title attended / Training Institute / Date of Completion

Educational background(please enclose copies of your certificates with this application)

Courses title attended / Training Institute/ Validating Body / Date of Completion

Employment background

Employer & Deptartment / Job Title & Clinical Area (if applicable) / Date from / Date to

Reference – Please supply a sealed employer’s/professional reference with your application form.

FURTHER INFORMATION

You are required to enter any information to support your application. Admission Tutors will be interested in your reasons for choosing the course(s), your career aspirations, relevant experience and information concerning your intellectual, social, sporting or other interests. You should give details of any non-examined subjects you are studying. If you have been out of education, please outline any relevant experience that may be considered in lieu of formal qualifications, either at home or in voluntary or paid work. You should explain any gaps or breaks in your career.

Declaration of Criminal Record – Please indicate if you have a relevant criminal conviction Yes/No

Applicants who answer ‘YES’ will not be automatically excluded from the application process. However, the University may ask for more information before making a decision.

Check List

Please enclose the following with your application form – without these documents the application process will be delayed

Reference enclosed Yes/No Copy of Passport enclosed Yes/No Copy of Professional Qualifications Yes/No

  • Mentorship applications require a Group Selection Form Yes/No
  • Non Medical Prescribing applications require a Supplementary Application form Yes/No

Signature______Print Name______Date______

(please use an electronic signature if emailing the form)

Please tick the box to agree to the Universities Terms and Conditions, which can be found on the University website.

Disabilities/Special Needs

Please tick the appropriate box(es) and in the space below indicate any additional support or facilities that you may need at the University. This information will initially be passed to the Faculty Disabled Students Co-ordinators who support applicants through the admissions process.

No know disability / / A / Specific Learning Difficulty (e.g. Dyslexia) / / G
Blind/partially sighted / / C / Deaf/have a hearing impairment / / D
Wheelchair user/mobility difficulties / / H / Autistic Spectrum Disorder or Asperger Syndrome / / B
Mental Health Issues / / F / Unseen disability – diabetes, epilepsy or a heart condition / / E
Two or more of the above disabilities/special needs / / J / A disability not listed above / / I

I am in receipt of the Disabled Students’ Allowance Yes/No

I am applying for or intend to apply for Disabled Students’ Allowance Yes/No

Please detail below any additional support or facilities you may need

Details of additional Support

Equal Opportunities Monitoring

I am Male/FemaleMy age today is Choose an item.

Please indicate your ethnicity by selecting the appropriate box. (This classification is based on the Census 2001).

50 ARAB16 GYPSY, TRAVELLER

33 ASIAN – BANGLADESHI90 NOT GIVEN (DOM=HOME)

34 ASIAN– CHINESE99 NOT GIVEN (DOM=OSEA)

31 ASIAN – INDIAN98 NOT GIVEN

39 ASIAN – OTHER80 OTHER

32 ASIAN – PAKISTANI49 OTHER MIXED

22 BLACK – AFRICAN11 WHITE

21 BLACK – CARIBBEAN43 WHITE AND ASIAN

29 BLACK – OTHER42 WHITE/BLACK AFRICAN 41 WHITE/BLACK CARIBBEAN