Guidance notes for completing your application form
1.Please complete all personal details, ensuring that you enter your date of birth – this is required in order for you to be entered onto the University database (SECTION A).
2.Please include an e-mail address that you check regularly as this will form our initial source of communication with you (SECTION A).
3.Please indicate in the relevant box, your professional experience and your highest previous academic qualification. If you have attained a Diploma, Degree, Foundation Degree or Award at Undergraduate or Postgraduate but not at Canterbury Christ Church University, please attach copies of your certificate(s) or transcript(s). Please note that you will be asked to produce the original document(s) (SECTION B).
4.Please give details of any disability that should be considered, if applicable (SECTION C).
5.Please tick the boxes with regard to ethnic origin and your profession (if any) (SECTION D).
6.Please indicate the source of funding. If you are self-funding, you will be invoiced separately by the University on commencement of your module (SECTION E).
7.If you are being sponsored, you must indicate the name of your Trust/Sponsor. You will need to obtain the correct signature of your authorised fund-holder on the form. Please note that this is in addition to the signature of your ward/line manager – these are not the same person (SECTION E, PART ONE).
In order to obtain the name of the authorised fund-holder, please check with either your ward/line manager or contact your relevant training and development department who should be able to advise you.
Please note that it is very important to obtain the correct signature as incorrect forms will be returned and this will result in a delay in processing your application.
8.Please ALSO obtain the signature of your ward/line manager.
9.Please sign and date your application (SECTION E).
10.Once completed and signed by the relevant parties, all forms should be returned to the address indicated on the application (SECTION E)
11.Please complete SECTION F if you are applying for a Foundation Degree.
12.SECTION G requires all students to identify where they heard about the programme they are applying to undertake.
13.Please complete SECTION H if you are applying for Degree (Level 6)or Masters (Level 7) study. If you are applying for the Foundation Degree you do not need to complete this section.
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Combined Application Form v1 April 2014
CANTERBURY CHRIST CHURCH UNIVERSITY
Faculty of Health and Social Care
SECTION A –TO BE COMPLETED BY ALL STUDENTS
MR/MRS/MISS/MS(please circle or add another title) / FORENAME:SURNAME: / PREVIOUS SURNAME (IF APPLICABLE):
Address (Home):
Tel No: / Address (Work):
Tel No:
Mobile: / Directorate/Division (if applicable):
Date of Birth:dd/mm/yyyy / Profession (e.g. OT):
E-mail address (This will be our main method of contacting you to confirm receipt of your application. Please check your Spam / Junk folder if you have not received confirmation in your inbox.):
Date of Commencement of Programme of Study (Month and Year):April 2016
SECTION B – TO BE COMPLETED BY ALL STUDENTS
Are you already registered for a programme of study? / Yes – Please continue to Section C. / No – go to question 2 below.Do you wish to apply for a new programme of study?
Best Interests Assessor modules / Yes – Please indicate which programme in the table below and complete the remainder of Section B. / No – go to question 3 below.
Do you wish to complete one or more standalone modulesthat are not part of a programme of study? / Yes – Please continue to Section C.
PROGRAMME
Please indicate which Programme & Awardyou are applying for (Please tick one box):
MSc / MA (Please indicate Programme name below e.g. Health & Wellbeing): / MSc / MA
Post-graduate Diploma
Post-graduate Certificate
BSc (Hons) Applied Practice (Health and Social Care) / BSc (Hons) Applied Practice (Health and Social Care (BSc (Hons)) (you must have a DipHE or equivalent for this award)
BSc Applied Practice (Health and Social Care) (BSc)(you must have a DipHE or equivalent for this award)
Graduate Diploma (you must have a BSc for this award)
Graduate Certificate (you must have a BSc for this award)
Foundation Degree Health and Social Care* / Foundation Degree
Certificate Higher Education Health and Social Care
University Certificates – Visual Impairment Rehabilitation, Orientation and Mobility, Low Vision
*If you areapplying to the Foundation Degree Health and Social Care you MUST tick one of the boxes below to identify your chosen pathway:
Acute Care / Generic Health and Social Care
Children and Families / Visual Impairment Rehabilitation
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Combined Application Form v1 April 2014
HIGHEST PREVIOUSQUALIFICATIONSPlease give details of your highest previous academic and/or professional qualifications in this section (e.g. NVQ, DipHE, BSc, BSc (Hons), MSc, MA).
Name and Address of School, College or University / Dates Taken / Qualification Gained / Results
ANY OTHER RELEVANT PROFESSIONAL QUALIFICATIONS
Name and Address of Institution / Dates Taken / Qualification Gained / Results
PLEASE ATTACH COPIES OF YOUR HIGHEST CERTIFICATE TO THIS APPLICATION
(ORIGINAL CERTIFICATES SHOULD BE BROUGHT TO THE REGISTRATION EVENT FOR VERIFICATION)
EQUIVALENT OR HIGHER LEVEL QUALIFICATIONSI have a qualification equivalent to, or higher than the one I wish to study / YES/NO
Accreditation of Prior Learning (APL)
Do you have credits completed either elsewhere or previously at CCCU that you wish to apply to APL into your Programme? You will need to complete an APL claim form which will be sent to your email address on receipt of your application form. / YES / NO
EMPLOYMENT/VOLUNTEERING EXPERIENCE
Please give details of voluntary and paid employment undertakenin the last 5 years (if you require more space, please attach an additional sheet to this application form)
Name of Employer / Dates / Duties and Responsibilities
PERSONAL STATEMENT (250 WORDS)
You are invited to set out any other information that you consider relevant to your application (e.g. details of previous study, special interests and the reason you are applying). You should continue on a separate sheet if necessary.
REFERENCE
Your referee should be able to give his/her opinion as to your fitness for the above programme, including academic and professional suitability where possible. This should be someone who knows you in a professional capacity i.e. Line Manager or Team Leader.
Name: / Address:
Relationship to applicant:
E-mail:
Telephone No:
REFEREE’S STATEMENT
SECTION C – TO BE COMPLETED BY ALL STUDENTS
DISABILITYDo you have a disability which we ought to consider? If yes please complete the table below.
DISABILITY (TYPE)
No known disability / Wheelchair user/mobility difficulties / Multiple disabilities
Dyslexia / Personal care support / A disability not listed
Blind/partially sighted / Mental health difficulties / Autistic Spectrum Disorder
Deaf/hearing impairment / An unseen disability: e.g. diabetes, asthma, epilepsy
SECTION D – TO BE COMPLETED BY ALL STUDENTS
ETHNIC ORIGINI would describe myself as:
White/British / Indian
White/Irish / Pakistani
White/Scottish / Bangladeshi
White/Other / Chinese
Black/Caribbean / Other (Please specify)
Black/African
Black/Other
FEE STATUS
We need information from you to determine your fee status. If this section of the form is not complete the University will presume that for fee purposes, you are an overseas fee payer.
Are you a UK National? / Yes / No
Are you an: / EEA National / Swiss National / Turkish worker in the UK
In which countries have you been resident for the last three years?
Country / Main purpose of your residence
1 / 1
2 / 2
3 / 3
4 / 4
Applicants not born in the European Union, please state:
Date of first entry to the EU: / dd/mm/yyyy
Date of most recent entry to the EU / dd/mm/yyyy
If you are not a UK National or EEA/Swiss National please state:
Country of birth:
Nationality:
Country of residence:
Address:
Do you require a student visa? / YES / NO / DON’T KNOW
Do you require a student visitor visa (for students studying six months or less) / YES /NO / DON’T KNOW
If you are not a UK/EEA citizen and do not require a student visa, what is your UK immigration status?
Indefinite Leave to enter/remain / YES / NO
Discretionary Leave to remain / YES / NO
Refugee status granted / YES / NO
Spouse of student visa holder / YES / NO
Dependent of student visa holder / YES / NO
Work Permit / YES / NO
Other (please state):
Start and end dates of current leave (UK Immigration Permission) if applicable / Start Date
dd/mm/yyyy / End Date
dd/mm/yyyy
SECTIONE – TO BE COMPLETED BY ALL STUDENTS
FUNDINGPLEASE CONFIRM HOW YOUR STUDIES WILL BE FUNDED
SOURCE OF FUNDING (please tick) / SPONSORED / SHARED / SELF
ONCE YOU HAVE COMPLETED THIS FORM, PLEASE RETAIN A COPYWHERE APPLICABLE RETURN IT TO YOUR AUTHORISED FUND HOLDER FOR APPROVAL& FORWARDING TO CANTERBURY CHRIST CHURCH UNIVERSITY.
STUDENTS WHO ARE BEING FUNDED BY THEIR EMPLOYER SHOULD COMPLETE PART ONE, SECTION E
STUDENTS WHO ARE SELF-FUNDING SHOULD COMPLETE PART TWO, SECTION E
PART ONE - FOR SPONSORED/SHARED SPONSOR STUDENTS ONLYAuthorised signatories:
Darent Valley Hospital / Sue Prime
East Kent Hospitals NHS Trust / Ann Broadhead / Lesley Bourne
East Sussex Healthcare NHS Trust / Barbara Gosden / Angela Jarvis
Kent Community Health NHS Trust / Helen Hatter
Kent and Medway NHS and Social Care / Lorna Hunt / Sue Rose / Emma Matthews
Maidstone and Tunbridge Wells NHS Trust / Marian Palmer
NHS Kent and Medway / Joanne Purkiss / Andrea Vigille
Medway Community Healthcare / Frances Regan / Sam Robinson
Medway Maritime Hospital / Tracy Perkins / Ursula Clarke
Pilgrims Hospice / Paula Evans / Suzz Keith
Southeast Coast Ambulance Service NHS Foundation Trust / Pam Fricker / Craig Mortimer
Name of Sponsor (BLOCK CAPITALS) if not listed above:
By signing below, I agree to pay the fees for the applicant to attend the programme/module, as detailed overleaf and I agree to provide a mentor (if required).
Name of Employer/Trust:
Contact telephone no:
Signature of Authorised Signatory:
Name of Authorised Signatory (BLOCK CAPITALS): / Trust/Company Stamp
Line Manager Agreement
I support this application and agree that a mentor will be provided (if required):YES / NO
Manager’s signature:Date:
If you are being sponsored by your employer, by signing this form you are consenting to the University sharing information with your employer about your attendance at Registration and on modules and results
Signature of student:Date:
PART TWO - FOR SELF-FUNDING STUDENTS ONLY
An invoice will be sent to you at the address given on page one of this application form.
By signing this form, you are agreeing to pay the tuition fees as invoiced. Details of the modules fees can be obtained from your Programme Administrator.
Signature:Date:
SECTION F – TO BE COMPLETED BY ALL FOUNDATION DEGREE STUDENTS AND THOSE STUDENTS WHO KNOW THAT THE MODULES THEY WILL BE UNDERTAKING REQUIRE ASSESSMENT IN PRACTICE
NOMINATED MENTOR OR PRACTICE ASSESSORMR /MRS /MISS /MS (please circle or add another title) / FORENAME:
SURNAME:
Address (Work)
Tel No: / Details of Mentorship Qualifications (if applicable)
E-mail address:
SECTION G – TO BE COMPLETED BY ALL STUDENTS
WHERE DID YOU FIND OUT ABOUT THE COURSE? (PLEASE TICK ALL THAT APPLY)Programme Flyer / Open Day/Event (when/where)
Programme Brochure / Journal/newspaper (publication/date)
Prospectus / Canterbury Christ Church School Liaison Activity
University website / Other (please state)
SECTION H – TO ONLY BE COMPLETED BY STUDENTS APPLYING FOR DEGREE (LEVEL 6) OR MASTERS (LEVEL 7) STUDY. STUDENTS APPLYING FOR THE FOUNDATION DEGREE DO NOT NEED TO COMPLETE THIS SECTION
MODULESIf known, please identify which modules you wish to apply for in the boxes below. Most modules are offered at one level only. However, where modules are offered at Level 5 and 6 andLevel 6 and 7, please indicate at which Level you wish to study. Please note that Level 5 modules do not contribute to the BSc programme of study and only one level 6 module can contribute to an MSc. Please contact the relevant Programme Director if you require pathway planning advice.
Academic Year:
Semester 1 (September – January) / Ring as appropriate
First Module
Location (where module is delivered in more than one location) / Law & Policy for Best Interests Assessors / Level
7
Second Module (only complete if you wish to study two modules in semester one)
Location (where module is delivered in more than one location) / Developing Advanced Practice Skills in The Best Interests Assessor Role / Level
7
Semester 2 (February – June) / Ring as appropriate
First Module
Location (where module is delivered in more than one location) / Level4 / 5 / 6 / 7
Second Module (only complete if you wish to study two modules in semester two)
Location (where module is delivered in more than one location) / Level
4 / 5 / 6 / 7
PLEASE SEE TIMETABLE FOR CUT OFF DATES FOR APPLICATIONS.
APPLICATIONS RECEIVED AFTER THE CUT OFF DATE MAY NOT BE ACCEPTED
ONCE YOU HAVE COMPLETED THIS FORM, PLEASE RETURN AS INDICTAED BELOW:
MSC CARDIOLOGY/MCH MINIMALLY INVASIVE SURGERY PROGRAMMES ONLY:
Allison Allen
Faculty of Health & Social Care
Medway Campus
30 Pembroke Court
Chatham Martime
Kent ME4 4UF
E-MAIL: / ALL OTHER PROGRAMMES:
Post Registration and Foundation Degree Health Team
Faculty of Health & Social Care
Canterbury Christ Church University
Canterbury
Kent CT1 1QU
E-MAIL:
PLEASE ENUSRE YOU HAVE INCLUDED THE FOLLOWING WITH YOUR APPLICATION WHERE APPLICABLE:
Photocopy of relevant professional qualifications
Photocopy of passport pages including photo and biographical details page,
all visa pages(if applicable) and Indefinite Leave to Remain page (if applicable)
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Combined Application Form v1 April 2014