THE UNIVERSITY OF HONG KONG
Carol Yu Centre for Infection
Department of Microbiology
School of Nursing
Certificate in Infection Control For Practising Nurses/ Infection Control Course(s)
The personal data provided in this form will be used for processing your application for enrolment on the relevant course, by the administrative and academic departments concerned.
This form should be completed and returned together with a cheque, which must be crossed and drawn in favour of “The University of Hong Kong”, to School of Nursing (4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong). Enquiry should be directed to Ms Annie Lau (Tel: 2819-2602 Fax: 2872 6079; email: chphku@ hku.hk)
1. PERSONAL INFORMATION
(Please fill in your full name [surname first] in block letters, as in your HKID Card/passport.)
Dr/Mr/Mrs/Ms/Miss*Name in Chinese characters (if any)
Address for correspondence: ______
______Email address: ______
Tel No.: ______
(Home) (Office) (Pager/Mobile Phone) (Fax)
2. PRESENT OCCUPATION
Current Position/ Department (Ward) / ( )Name and address of organization
3. QUALIFICATIONS
4. COURSE ENROLMENT AND COURSE FEE PAYMENT
I wish to enroll:
□ Certificate Course (Fees: HK$5,400/ HK$4,800*/HK$3,000#)
□ the following individual module(s) (HK$1,000*/HK$800/ HK$500# for each module)
□ Module 1: 23-24 Nov 2013 / □ Module 4: 22-23 Nov 2014 (Tentative)□ Module 2: 26-27 Apr 2014 / □ Module 5: Apr 2015 (Date to be confirmed)
□ Module 3: 12-13 July 2014 (Tentative) / □ Module 6: Jul 2015 (Date to be confirmed)
* Special fees will be offered to alumni and Honorary Tutors of the School of Nursing, HKU
(Certificate Course: HK$4,800; Individual Module: HK$800 each)
# Special fees will be offered to current part-time students/ staff of the School of Nursing, HKU
(Certificate Course: HK$3,000; Individual Module: HK$500 each)
Note: The registration fee is non-refundable.
I would like to enjoy the special fees offered to:
□ Alumni (HKU No.:______; Year of Graduation: ______)
□ Honorary Tutor ☐ Current Part-time Student/ Staff (HKU No./ Staff No. ______; Programme: ______)
Date: ______Signature: ______