Organiser: the Society for the Promotion of Hospice Care

Organiser: The Society for the Promotion of Hospice Care

Co-organiser: Hong Kong Palliative Nursing Association Sponsor: The TUYF Charitable Trust

2018 End-of-life Care Education Programme: Enrollment Form

Part A Personal Particulars (Please complete Part A in BLOCK LETTERS)
Surname
Given Name
Chinese Name
E-mail / Gender : Male □ Female □
Mobile No. / Other Contact No.:
Part B Occupation Details
Organization / Hospital
Department / Wards / Years since qualification:
Position / Professional
Part C Additional Information
Have you attended any course on hospice palliative care / end-of-life care before?
Have you had any clinical experiences of hospice palliative care?
What is your expectation of the course?
Part D Seminar / Course Preference (please mark “X” in the appropriate box)
 / 26 June 2018 (Tue) / Concept on palliative care / HK$100
 / 3 July 2018 (Tue) / How are terminally ill patients cared in hospice setting / HK$100
 / 10 July 2018 (Tue) / Self-awareness on life and death / HK$100
 / 17 July 2018 (Tue) / Spiritual needs of patients with advance illnesses / HK$100
 / 24 July 2018 (Tue) / Care of the imminently dying / HK$100
Bank Name:______Cheque no.:______Amount:HK$

Remarks: Please submit the completely filled enrollment form with:

1)the course fee by cheques payable to “SPHC” with the applicant’s name and course name indicated at the back.

Please use one cheque for each seminar / course.

2)a copy of employment ID (e.g. staff card, name card) a self-stamped (HK$2) & addressed envelope if no e-mail contact could be provided.

(Size of the envelop should be within 165mm x 245mm)

3)Please send the application to the following address:

Jockey Club Home for the Hospice, SPHC (No. 18, A Kung Kok Shan Road, Shatin, New Territories)

“Application for EOLC Education Programme (June-July 2018)”

-Applicants will be informed the status of application by 1 week before the course commences.

- Please contact Ms. Candy Kwok at 5904-9429 or if there is no information received by then.

*** Incomplete Application will NOT be Processed *** Fee is non-refundable.

The Society for the Promotion of Hospice Care (“SPHC”) undertakes to comply with the requirements of the Personal Data (Privacy) Ordinance to ensure that personal data being kept are accurate and secure. To safeguard the interest of our data subject, SPHC collects personal data from you only for the purposes of issuing receipts, confirming our services/activities with you, and notifying you of future news and activities of SPHC.

Please tick the box below to indicate your preference.

□ I wish to receive future information of SPHC. □ Ido not wish to receive future info

EOLC-3-7-11 Application form