FACULTY OF HEALTH SCIENCES

MODULE REQUEST FORM – in order that we are aware of what module(s) you wish to study please uploaded this form with your application through My Portal. You should also keep a copy for your own records.

PERSONAL DETAILS
NAME:
PREVIOUS NAME : / TITLE:Mr/Mrs/Miss/Ms / DOB:
E-MAIL ADDRESS(work or personal):
STAFFORDSHIRE UNIVERSITYSTUDENT REGISTRATION NUMBER (if applicable):
EMPLOYER NAME AND ADDRESS (include Trust title, Ward and Dept if appropriate):
PLEASE LIST THE MODULES YOU WOULD LIKE TO APPLY FOR IN THE BOX BELOW.
Term
1, 2 or 3 / Start Date / Level
3,4,5,6,7 / Module Title / Site
PAYMENT OF FEESPlease complete one of the following sections
SECTION A - PAYMENT FROM LEARNING BEYOND REGISTRATION COMMISSION
The following Trusts have a Learning Beyond Registration commission with the Faculty of Health Sciences and this form has to be approved and signed by the appropriate signatory listed below:
  • Burton Hospitals NHS Foundation Trust – Vannessa Rolinson
  • Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust – Helen Smith/Jane Downey
  • Shrewsbury and Telford Hospital NHS Trust –Sarah Bloomfield/Philip Fewtrell
Staff from the following Trustsonly will need to upload the confirmation of funding letter they receive from their Trust and a signature is NOT required on this form.
  • Staffordshire and Stoke on Trent NHS Partnership Trust– Clare Spencer
  • Shropshire Community Health NHS Trust – Sonia Orr

NAME OF TRUST:
SIGNATURE (Authorised Trust Signatory):
NAME (Please print):
If you are unable to obtain authorisation at the time of application, please upload this form giving details of your module choice. Please pass a copy of this form to the Authorised Signatory who will return it to the Faculty.
SECTION B - PAYMENT BY MY EMPLOYER /SPONSOR
At enrolment you will need to upload either a copy of your purchase order/sponsors letter from your employer/sponsor. Your enrolment will be put hold until this is cleared by our Finance Dept.
Please note that if this is not provided you will be invoiced for your fees.
SECTION C - FUNDING MYSELF
At enrolment you will be required to pay 100% of fees if less than £511, otherwise 50% at enrolment and the remainder in instalments.

If you have any queries please contact the Lifelong Learning Team on 01785 353766