Registration Form for Alliance Healthcare

Flu Vaccination Training 2014

How to fill in this form

  • This registration form needs to be completed to confirm your place on your chosen training course
  • Please complete either the section foronline trainingor the section forface to face training
  • Only details for one pharmacist can be filled in per form
  • All pharmacists must complete all sections of ‘Your Details’ on the second page
  • Completed, signed and dated forms should be returned to Alliance Healthcare as per instructions on page two

ONLINE TRAINING for pharmacists who have undertaken recognised flu vaccination face to face practical training in 2013 and/or 2012[1]

Name of previous flu training provider
Date of last training (DD / MM / YYYY)
/ / /

Please note the certificate from your previous training provider needs to be provided or in the event the training certificate has been misplaced a self-certification form must be completed to confirm competency;failure to produce one of these document could result in your withdrawal from the online training course

OR

FACE TO FACE TRAININGfor pharmacists who are new to flu vaccination training or who trained in 2012 or 2013and would like to refresh their practical skills or who last undertook practical training in 2011 or earlier

FACE TO FACE TRAININGLOCATIONS
Please tick the location you wish to attend
AM: from 8.45am – 12.45pm and PM:from 1.30pm – 5.30pm / COURSE DATES / PLEASE TICK YOUR PREFERRED TIME
AM OR PM
Manchester / 31 August / AM / PM
Bristol / 14 September / AM / PM
Edinburgh / 14 September / AM / PM
Watford / 14 September / AM / PM
Croydon / 21 September / AM / PM
Birmingham / 21 September / AM / PM

YOUR DETAILS – please complete all fields

Pharmacy Name
Alliance Healthcare Account Number
Your Name (please note only pharmacists can undertake the flu vaccination training)
Pharmacy Address
Postcode
Your Contact Phone Number
Email Address (to provide you with booking confirmation and a link to the online training)

Signing your registration form and sending it back

The cost of the training is £129.00+VAT for face to face training and £60.00+VAT for the online training.

Concessions are also available for groups of fifteen or more pharmacists. If you are part of a group of fifteen or more pharmacists attending our flu training please tick here

Alliance Healthcare reserves the right to cancel any training event without prior notification.

I confirm that I will be attending the Alliance Healthcare flu vaccination training on the date I have specified above. I authorise Alliance Healthcare to debit the fee from my account and I accept that non-attendance on the above date will result in the deduction of the agreed fee from my account.

Signature / Date (DD / MM / YYYY)
/ / /
Full Name

Please return your fully completed registration form to Pharmacy Professional Services

Post: Pharmacy Professional Services, Alliance Healthcare, 43 Cox Lane, Chessington, Surrey, KT9 1SN

Email:

Fax: 0203044 8993 Tel: 020 3044 8434

Registered details: Alliance Healthcare (Distribution) Limited, 43 Cox Lane, Chessington, Surrey, KT9 1SNPage 1 of 2

A company registered in EnglandWales. Registered number: 3446039

[1] Applies to training recognised by an Independent Medical Agency (IMA) providing Patient Group Directions (PGDs).