Nicotine and Tobacco: Postgraduate CPD Course for Practitioners 2018
COURSE APPLICATION FORM
1. About You:
Title ______Surname ______First name ______
Date of birth: ______Gender: (√) Male ____ Female _____
Home address, including postcode ______
______
Country of Domicile (if other): ______
Nationality: ______Tel No Daytime: ______
Mobile: ______E-mail: ______
2. Professional & Academic:
Job Title and Profession: ______
Organisation name and address: ______
______
Please describe your current role, interest in this topic and reasons for wishing to attend the course:
3. Course Choices & Costs
If you book and pay before 28th February 2018 the cost is: £499 unaccredited or £649 for students seeking accreditation. From 1st March, the price is £599 unaccredited or £749 if seeking accreditation.
In all cases these prices cover lunch on arrival as well as lunches and refreshments throughout the course, a networking dinner on Monday evening, 21st May, and a packed lunch on departure. Accommodation is not included but can be booked on your behalf (see below).
Please indicate (√) if you wish to take the course as a stand-alone course for professional development (unaccredited) or accredited at Masters Level (10 credits). NB: If you choose the latter, you will be required to submit a 3000 word assignment for assessment after the course and you must have an undergraduate degree in any discipline.
I wish to take the course as a stand-alone course, without accreditation. è OR
I wish to take the module with accreditationè Please give details of your undergraduate degree or higher qualification if you have one:
Highest Qualification: ______Awarding Institution: ______Year: _____
4. Accommodation
A block of rooms has been reserved at the Conference venue Stirling Court Hotel http://www.stirlingcourthotel.com/ which is located in the grounds of the Stirling University Campus. Stirling Court Hotel is one of only two venues in Scotland awarded the highly coveted Conference Centre of Excellence Award. The Centre offers a range of excellent facilities. The cost for accommodation is £61.00 per night including breakfast.
For those of you with further to travel, there is also the option of staying on the night of Sunday 20th May. Do not feel obliged to stay on site if you would prefer to be at home or source your own accommodation. Please indicate your accommodation plans below:
I will arrange my own accommodation è
I wish to book accommodation and be invoiced for it as indicated below: è If so, please indicate the nights you wish to stay at Stirling Court: (√)
Sunday night, 20th May / Monday night, 21st MayTuesday night, 22nd May / Wednesday night, 23rd May
4. Payment
Payment can be made through The University of Stirling’s Online Shop which offers a convenient way to pay using a secure online payment system.
Once your application has been accepted a link to the Online Shop will be sent to you
5. How did you hear about this course?
Please tick (√) all the boxes that apply and give brief details in the box following:
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q www.ukctas.ac.uk website or other website: which one?*
q Twitter: please indicate the twitter account if possible*
q Facebook: please give details if possible*
q At a conference: which one?*
q Word of mouth recommendation: from whom?*
q Direct email: from whom?*
q Direct postal mail
q My employer
q Other*
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* Please give details:5. Additional Needs & Further Information
q If you have any physical or other disability, or a medical condition that might necessitate special arrangements or examination facilities, please enclose relevant details with this application or tick this box and we will contact you.
q To help us reduce the risk of harm or injury to our students by the criminal behaviour of other students, we must
know about any relevant criminal convictions that an applicant may have. If you have a relevant criminal conviction, please tick this box. You will be contacted in confidence to provide more details, and any information provided will be treated with the utmost sensitivity.
q If you have any special dietary requirements please tick this box and describe here:
______
6. DATA PROTECTION
The University processes for educational purposes the personal information about which you have given on your application form. By giving this information you consent to all such personal information being made available for
official purposes to academic staff and support staff at the University of Stirling and other universities in the UK Centre for Tobacco and Alcohol Studies. Except where disclosure is required by law, or where you have separately agreed to disclosure to another organisation, such information will be kept confidential within the University.
7. DECLARATION
All applications are considered on an equal basis which takes no account of religious, racial, gender, age or political considerations in admitting students.
The University of Stirling’s programmes are subject to a continuous process of review. While every effort has been made to ensure the accuracy of published material at the time of going to press, the University of Stirling will not be liable for any errors or omissions. The University of Stirling reserves the right in every case at its discretion to vary the contents of academic programmes or parts of programmes, to offer new programmes, to discontinue programmes and to cancel programmes in the event of low enrolment.
I hereby apply for this course at the University of Stirling and I confirm that the information given is correct. I confirm that the documentation I have supplied with my application is genuine, and I understand that the University of Stirling will withdraw my application if any aspect of my application is found to have been falsified. I hereby acknowledge that the University of Stirling will accept no liability for my tuition fees or living expenses in the event of my acceptance onto the course.
Signed: (electronic signatures are fine)______Dated: ______
RETURN FORM TO: CPD Team BEFORE 9th May
NB: EARLY BIRD RATE APPLIES for APPLICATIONS PAID FOR BY 28th February only
If you have any queries about applying for the course, invoicing and registration please contact:
CPD Team
Address: Room G4, Pathfoot Building, Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA
Email:
Phone: 01786 466336
If your query relates to course content, the assignment for accreditation, or the suitability of the course for your needs, please contact:
Allison Ford
Email:
Phone: 01786 467357
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