Paediatric Training-Application Form
 

Advanced Life Support e-learning Course

(All * marks are mandatory)
 


Full name (this is how you wish your name to appear on your course certificate)
Title *
Forename(s) *
Surname *


Name that you are known/called by (this will go on your ID Badge)
Name *


Personal Details
Address Line 1 *
Address Line 2
Address Line 3
Town / City *
Postcode *
Country *
Mobile Number *
Work Number
Ext-Bleep Ext: Bleep:
Email *
Special Physical Needs * [Type No, if you have no special needs]
Special Dietary Needs * [i.e. Gluten free, Any allergy, Halal, No Beef, No Pork etc.
Type No, if you have no special dietary needs]


Professional Details
Job Title *
Speciality *
GMC/NMC/HPC Number
(UK applicants only) *
[Type N/A if you are not UK Applicant]
Which NHS Health Board or NHS Trust do you work in?*
Name of Hospital or Institution *
Address of Hospital or Institution *
Address Line 1*
Address Line 2
Address Line 3
Town/City*
Country*
Postcode*


Username/Password (For Member Login)
Username * [This must contain a combination of letters and at least one number (0-9)]
Password * [Minimum character 8, maximum 12, NO special character (&,!,$,%,...) Please]


Photo Upload (For Course Administration)
Please upload a recent photo of yourself. *
[Please ensure that the photo you are uploading is named in the following format: 'firstname_surname', e.g. if your name is David Jones then name your photo file as David_Jones.jpg, before uploading it. We accept photo files of any of the following formats: gif, jpeg, jpg, pjpeg, x-png, png.]


Course Details
Please select your course
Please select your session


Potential Instructorship
If you do well at the course, would you like to be considered for instructorship?


Course Payment
Are you paying your course fee/administration fee by yourself or is any other trust/organization paying on your behalf? [If you are normally funded by your Health Board, you will need to initially pay the fee yourself, then re-claim the cost from the Health-Board]

Please specify:
(e.g. Self / Health Board etc..)

Disclaimer: Any interaction with your Health Board or responsibility for claiming funding support lies solely with you, the candidate, and not with the course organiser.
Privacy & Policy Accepted*
(See our privacy and policy document)
Terms & Conditions Accepted*