Pump Curriculum - Educator Trainingworkshop

DAFNE

Pump curriculum - educator trainingworkshop

Application form

Please read the notes on page 2 before completing the application form. All fields marked * must be completed prior to submission.

Personal Details

First name*

Surname*

Profession*

Centre name *

Email*(refer to note 1.2)

Daytime telephone number*(refer to note 1.2)

Bleep (if applicable)

Fax number

Special requirements (dietary or other):

Pump training workshop date

Date of pump workshop*

Disclaimer

Upon completion of the pump curriculum training workshop I agree to comply with the DAFNE internal quality assurance (IQA) and audit process, as detailed in pump training workshop supporting information document (P01.045).

Signature ...... Date ......

Central DAFNE office use only

Payment method: PO Visa Cheque

Invoice raisedInvoice number

Payment receivedTraining place confirmed (date)

DAFNE ©F02.016, version 4 – March 20161

Completion of application form – personal details

1.1All fields of the application form marked with an *must be completed.

An application form received with missing information will be returned to the applicant and will delay the allocation of a training place.

1.2Please ensure your email and telephone details are correct, so that we can contact you if we have any queries regarding your application form.

1.3Please ensure you are available to attend the preferred workshop before completing the workshop date on the application form. Training places are non transferrable and training fees are non refundable.

1.4Upon completion of the form please send to:

Central DAFNE

Diabetes Resource Centre

NorthTynesideGeneralHospital

Rake Lane

North Shields

NE29 8NH

Email to or fax to 0191 2934276

Educator requirement

2.1Only educators who have completed all steps of the DAFNE educator programme and are a registered DAFNE educator can apply for a place on the workshop.

Cost and payment method

3.1The training cost per delegate is £125.00 (this may be subject to change). The fee is based on a minimum of 10 delegates per workshop. If numbers fall below the minimum the workshop may be cancelled.

3.2Training places will only be confirmed upon receipt of full payment and the provision of all essential information on the application form. Note: Training places are nontransferrable and nonrefundable.

3.3Payment can be made by:

Official purchase order –central DAFNE preferred method (submitted with application form)..
Debit/credit card – If you wish to pay by card please contact central DAFNE on 0191 2934115; the payee will be transferred to NHCT finance department to process payment. Training place will be confirmed upon confirmation of payment transaction.

Further information can be obtained by contacting central DAFNE on 0191 2934115 or email