UNIVERSITYDENTALHOSPITAL OF MANCHESTER

CentralManchesterSchool for Dental Care Professionals

Post Registration Courses - APPLICATION FORM

Please complete this form in BLOCK CAPITALS and post with your payment to: , The Central Manchester School for Dental Care Professionals, 3rd Floor, Staff-Side, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH.

Tel: 0161 2725670 / Fax: 0161 272

NAME OF COURSE (Please Circle/highlight)

DENTAL SEDATION ORAL HEALTH EDUCATION ORTHODONTIC NURSING

Course Start Date: - …………………………………………………………………………………………

PERSONAL DETAILS

Surname

First name(s)

Postal Address

Post Code:GDC Registration Number:

Daytime Telephone number (including STD code): Mobile Telephone Number:

Email address:

 PRACTICE DETAILS

Practice Name & Address:

Post Code: Telephone Number:

Name of Supervising Dentist:

Supervising Dentist’s GDC Registration Number:

QUALIFICATIONS

Please state the Dental Nursing qualification you have achieved:-

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PAYMENT

The full cost of the course is £750.00per candidate. NHS practices that come under the catchment areas of the North West Deanery (Cumbria & Lancashire, Cheshire & Merseyside & Greater Manchester) are eligible for part funding towards the course fee. If you are eligible for a funded place,the course fee will be £250.00. At interview, you will be required to either bring a cheque payable to CMFT or bring a debit/credit card to make payment at our accounts department or if you wish for an invoice to be raised please complete the section below.

In cases where organisations need invoicing, please provide the full details of who to send the invoice to and circle the amount payable £250.00/£750.00.

Name:

Position:

Address:

Email:

CANCELLATIONS

Cancellations received at least seven days before the course start date will be refunded, subject to a 25% administration charge. There will be no refund of course fees after this time.

DECLARATION

I agree to attend all training sessions and complete the training programme; I confirm that I am able to meet the clinical requirements for the record of competence (please refer to the fact sheet). I agree to my employer receiving updates on my progress on the course.

If you do not submit your Record of Competence by the specified deadline date, you will not be able to sit the examination. The NEBDN will charge you, the candidatethe amount of £30.00 in order to defer to the next examination.

Signature of applicant: ………………………………… Date: …………………………………….

GDC Registration Number …………………….

Please note; Your GDC registration may be at risk if you knowingly make a false declaration.

CHECKLIST

Please ensure you have included the following with your application:

Completed application form

Authorisation letter if invoice requested

Post Registration Course - APPLICATION FOR COURSE FUNDING

Describe your current role:

Do you have a personal development plan? (circle)

If you do not have a personal development plan, would you like a

Deanery Facilitator to assist you to develop a plan?

(please contact Christine Sutton on 0161 625 7658 to arrange a visit)

Does the practice have a practice development plan?

Describe how this training would benefit your role?

Describe how this training would benefit the practice and impact on delivery of services?

This training is part of the practice development plan and as the employer I agree to release the applicant for training

Signature ofEmployer:…………………………..……………… Date: ………………….…………………………….

Signature of applicant: ……………………………………………Date: …………………..…………………………….

For office use only
Application Approved for funding
Interview Letter Sent

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Post Registration Course Application Form 2016