Dietetics Placement Allocation

LMS1 FORM FOR STUDENT APPLICATIONS FOR ALLOCATION

FOR CLINICAL PLACEMENT

(Please return this form to your Placement Allocation Officer. Any queries please contact

0113 812 9232 or email )

Before completing this form you must read the guidance paper "LEEDS BECKETT CLINICAL DIETETIC PLACEMENT ALLOCATION PROCESS" which will be given to you in April / September.

Please complete all sections electronically in black, so that when these forms are photocopied they are legible. You will then need to sign a printed copy. It should be noted that this form will be forwarded to the Trust(s) at which you will undertake your placement(s).

SECTION 1: PERSONAL DETAILS

University / Course / UG / PG
Year Started on Course
Surname / First Names (underline preferred name):
Title: / Mr/Mrs/Miss/Ms/Other / Date of Birth:
Term Time Correspondence Address / Permanent Home Address:
Postcode / Postcode
Telephone Number / Home Telephone Number:
Email: / Mobile Number
Enhanced CRB number: / Date of issue:
Course Funding Status: You are all within our NHS contract and will be receiving a bursary (fees paid).
Do you receive a contribution towards your living expenses: YES or NO
If yes, please indicate approximate value.
If no, do you receive parental contribution, please give approximate value. All needed as I don’t receive a loan.
Previous Degree & University: / Are you a car owner? YES or NO
Do you have a current
driving license? YES or NO

SECTION 2: PRIORITY STATUS

Are you a priority for allocation? / No / Yes
If yes, please attach a completed LMS2 form "Student application for priority allocation for A, B or C clinical placement"with supporting evidence. Details of your priority status and supporting evidence will be confidential to your Placement Allocation Officer and if necessary shared with the Placement Allocation Team.

SECTION 3: ADDITIONAL INFORMATION

Please provide any additional details you feel may be appropriate for the trainer(s) facilitating your placement(s) e.g. previous work experience, interests within dietetics and socially (please summarise in space below).

SECTION 4: SIGNATURES

I have read the guidance booklet "LEEDS BECKETT CLINICAL DIETETIC PLACEMENT ALLOCATION PROCESS" and agree to abide by the terms and conditions of the allocation process.
Students Name (please print) / Date
Student ID Number
University Tutors Name (please print) / Date

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