Trent Simulation and Clinical Skills Centre at QMC
Application Form
Course: Laparoscopic Theatre Practitioners Course
Date: Thursday 19th May 2011
Duration: 1 Day
Fee: £25.00 cheques made payable to “Nottingham University Hospitals NHS Trust”
Venue: Trent Simulation and Clinical Skills Centre
Queens Medical Centre Campus, Nottingham
Please Note: Places are allocated on a first come, first served basis.
Please complete, return this application form and cheque asap.
PERSONAL DETAILS (please enter details clearly)
Title: ______Male Female
Forename: ______
Surname: ______
Position: ______
Department: ______
Hospital: ______
Address for all Correspondence: ______
______
______
Post Code: ______
E-Mail: ______
Mobile No: ______
Any Special Dietary Requirements: ______(eg Vegetarian)
How did you learn about this course? Recommended by a colleague
(Please circle where appropriate)
Via Lapco
Flyer displayed in Departmental Office
Other (please specify) ______
TERMS AND CONDITIONS
Confirmation of your place will be sent as soon as possible.
Places can only be awarded on receipt of the relevant fee.
Whilst every attempt will be made to keep the previously advertised dates, Trent Simulation and Clinical Skills Centre reserves the right to reschedule or cancel a without prior notice any course date. In such circumstances reasonable efforts will be made to notify candidates but the Trust will not accept any liability in respect of any hotel or travel costs.
As this is an intensive course, candidates need to have time to adequately assimilate the pre-course material. Therefore, it may not be possible to find a replacement candidate should you withdraw, and as a consequence the following cancellation fees have been introduced.
I understand that the following cancellation fee will be levied:
4 weeks before course date: HALF FEE
Less than 4 weeks before course date: FULL FEE
Submission of the Course Application form indicates that you are aware of the Centre’s Health and Safety policy.
Please tick the box to confirm that you have read the terms and conditions above.
PAYMENT DETAILS
It is YOUR responsibility to ensure that payment is received prior to the course date. Application forms shall be returned if not accompanied with the correct course fee.
I enclose a £25.00 CHEQUE made payable to: “Nottingham University Hospitals NHS Trust”
Please return this form to:
Louise Johnson
Course Co-ordinator
Trent Simulation and Clinical Skills Centre
c/o Postgraduate Centre
Queens Medical Centre Campus
Derby Road
Nottingham
NG7 2UH
E-Mail:
The Trent Simulation and Clinical Skills Centre maintain a secure database for the organisation of its courses. Information you supply on this booking form will be held in accordance with the Data Protection Act. The information will be retained to facilitate future bookings and to inform you of other events offered by the Trent Simulation and Clinical Skills Centre at QMC.
Please tick the box if you do not wish information supplied to us to be used in this way.
TS&CSC/Course Files/Laparoscopic Theatre Practitioners Course/Application Form