Workforce Development Application Form

Return to Practice (CLP5/6018Y)

Personal Details
Student number (if previously studied with us):
Title (e.g. Miss/Mrs/Mr):
First Name:
Family Name:
Previous Name (if applicable):
Date of birth:
Nationality:
Professional registration number (NMC/UKCC):
Contact Details
Home Address:
Personal Email Address:
Contact Telephone Number:
Academic/Professional Qualifications
Please give details of your professional and academic qualifications in chronological order, beginning with the most recent:
Title of award/course/module: / Name of Institution: / Level of study: / Credits awarded: / Grade: Class of degree / Date Awarded:
e.g. Diploma in Nursing / Kingston University / Level 5 / 120 / Pass / June 2013
Employment Information
Name of current employer:
Current Job Title:
Employer’s address:
To assist in selection of an appropriate practice placement, please provide details of the field/branch of nursing where you previously worked
Declaration of fitness to practice
I confirm that I am not or have not been subject to fitness to practice/ disciplinary hearing in the past either locally or nationally and none pending:
Signature of applicant:Date:
Declaration of criminal record
The Rehabilitation of Offenders Act
The educational programme for which you are applying is exempt from the Rehabilitation of Offenders Act. This means that you must declare any criminal convictions even if they are spent. (Please note that a conditional discharge is a conviction). You must therefore answer this question:
Have you ever had any criminal convictions? / Yes / No
Protection of Children: Disclosure of criminal background of those with access to children
The Terms of Department of Health circular (Ref HC(88)9) require college authorities to check with local police forces the possible criminal background of anyone who may have substantial access to children. Refusal to give your permission for this check could prevent further consideration of your application. If necessary, you are required to list all convictions, bind-over orders and cautions (including verbal cautions) as part of the initial recruitment procedure. Please therefore answer both the questions below:
Do you agree to a police check? / Yes / No
Have you ever been convicted of any criminal offence, bound over or cautioned? / Yes / No

Failure to disclose convictions, bind-over orders and cautions could result in the termination of your course or disciplinary action.

Declaration of health
Please state how many days absence, due to illness, from employment you have had in the past two years and on how many occasions:
Applicant’s Declaration
I confirm that the information given in this application form is accurate and may be verified on request by the University. If any information on this application form is found to be false, this may lead to the withdrawal of an offer of a place with St George’s, University of London.
I understand that the data in this form will be used to process my application and manage my studies. My studies are funded by Health Education South London (HESL) and information about my studies including attendance, results and academic performance will be shared with HESL
I understand that if I am found guilty of any case of academic dishonesty or cheating while studying at St George’s, University of London; the Course Director/Head of Undergraduate CPPD will inform the sponsor HESL.
Signature of applicant: Date:
Under the Data Protection Act 1998, the information you supply will be held in strict confidence for the purpose of ascertaining your suitability for your chosen course of study. In the event that you become a registered student with the University your data will form the basis of your student record.
What happens next?
Please submit your form to the PPD Programme Office:
You will receive an automated electronic acknowledgement of receipt. (If someone else has submitted your form on your behalf please check with them that they have received the receipt.)
After your application has been assessed and processed interview dates will be sentvia e-mail correspondence, so please do ensure you check your emails regularly.

It is essential that every section of the application is completed as incomplete forms will not be processed.

Equal Opportunity Monitoring Form

The completion of this form is voluntary, but the information it contains helps us to monitor and improve our equal opportunities policies and procedures.
This sheet is not used in the short-listing process. All short-listing is based on merit.

Nationality:
Ethnic Origin / Disability
White / No disability
Black or Black British - Caribbean / Specific learning difficulty (for example, dyslexia)
Black or Black British - African / Blind or partially sighted
Other Black Background / Deaf or hearing impairment
Asian or Asian British - Indian / Wheelchair user or mobility difficulty
Asian or Asian British - Pakistani / Personal care support
Asian or Asian British - Bangladeshi / Autistic Spectrum Disorder or Asperger Syndrome
Chinese / Mental health difficulty
Other Asian Background / Unseen disability e.g. diabetes, epilepsy
Mixed-White and Black Caribbean / Other, please specify below
Mixed-White and Black African
Mixed-White and Asian
Other Mixed Background
Arab
Gypsy/ Traveller
Other Ethnic Background
Not Known

If you have a disability or specific learning difficulties (such as dyslexia) and will require reasonable adjustments to be made while studying at St George’s, University of London, please inform the PPD Programme Office and contact the Disability Advisor ( or 020 8725 0143)

For general information about studying with a disability please see: Please note that some adjustments may only be possible if we are informed well in advanced of you starting your course.