APPLICATION FORM FOR ADMISSION DIPLOMA IN PEDIATRIC NURSING (One Year Post Basic Specialized Diploma Course)

Transcription

1 APPLICATION FORM FOR ADMISSION DIPLOMA IN PEDIATRIC NURSING (One Year Post Basic Specialized Diploma Course) GOVERNMENT OF SINDH NATIONAL INSTITUTE OF CHILD HEALTH RAFIQUI SHAHEED ROAD KARACHI Phone: Ext:282 Fax:

2 Introduction of National Institute of Child Health 1962: The first children ward was opened in Karachi in the building of the present Basic Medical Science Institute in Jinnah Hospital premises. 1973: The six story building was finally occupied. 1979: President of Pakistan Late Gen. Zia-ul-Haq declared the hospital as National Institute of Child Health the First children hospital of the country In April 1990, NICH separated from JPMC, and made an attached department of the Federal Ministry of Health. NICH is a 500 bedded hospital, run under administrative control of Federal Ministry of Health. After 18 th amendment now, it is under control of Sindh Government. Introduction of School of Nursing, NICH School of Nursing is a part of National Institute of Child Health Karachi. It was established under the prime Minister s Karachi Package in Recognized by Pakistan Nursing Council in 2001 Examination body is Sindh Nurses Examination Board Karachi. Clinical affiliation is with NICH., JPMC & NICVD Karachi Nursing Courses Offer Diploma in Pediatric Nursing ((One Year Post Basic Specialized Diploma Course) Diploma in General Nursing (Three Years Course) Diploma in Midwifery (One Year Course) Nurse Aid (One Year In-House Certificate Course) Our Vision is: To become a leading globally recognized Centre of Excellence and innovation in the field of Pediatric Nursing Education. Our mission is: To attain international excellence and innovation in Pediatric Nursing Education and to produce highly skilled and specialized Pediatric Nursing workforce with a view to foster child s health in our country and disseminate contemporary knowledge in all sub-disciplines of pediatric nursing as in pediatric medicine, pediatric surgery ect. 2

3 Reg. No. For CTS use only GOVERNMENT OF SINDH NATIONAL INSTITUTE OF CHILD HEALTH KARACHI Photo APPLICATION FORM FOR ADMISSION Diploma in Pediatric Nursing (One Year Post Basic Specialized Diploma Course) Bank Branch/Code (To be filled by candidate s own hand writing and in BLOCK LETTERS). 1. Bio data: a. Applicants Name: (According to Matric Certificate) b. Applicants Father/Husband/Guardian Name: c. Date of Birth: Gender: Marital Status: d. Religion: Nationality: e. CNIC/Smart Card No: Expiry Date: f. Domicile(Dist-Province): Domicile No: g. PNC Registration No: Expiry Date: 2. Address: a. Present Address: Deposit Date Note: Application Form will not be entertained without Original Deposit Slip of CTS copy. Phone No (Landline): Fax No. Mobile No: b. Permanent Address: Phone No (Landline): Fax No. Mobile No: c. Postal Address: Phone No (Landline): Fax No. Mobile No: 3

4 3. Qualification: a. Academic/General Qualification Name of Academic S. No Qualification 1 Matriculation Board/University Name Passing Year Marks Obtained Total Grade/ Division 2 Intermediate 3 4 b. Professional Qualification Professional S. No Qualification 1 General Nursing Board/University Name Passing Year Marks Obtained Total Grade/ Division Professional Experience: (List all post held since registration in Nursing) S. No Post Held Institution Location Date(Period) From To 4

5 5. References: Give the references of three individuals (Not Relatives) to whom you are well known. a. One must be from the Director Nursing/CNS/Principal of yours Institute of Nursing b. One under whom you have worked for at least two years. c. One must be from your present employer. S. No Name Position Address Signatures Person to be notified in Emergency: Name: S/o: Relationship: Address: CNIC No: Phone No (Landline): Fax No. Expiry Date: Mobile No: 7. Following Documents Must Be Attached With Admission Application Form a. Four recent passport size photographs b. Attested copy of Diploma in General Nursing and Marks Sheet of all the three years Matric and F. Sc.( Board Certificate and Mark Sheets). Experience certificate from last employer NOC/leaving certificate from last employer Active PNC Registration Card Active CNIC/Smart Card Domicile, PRC. Three letters as mentioned above Medial fitness certificate 5

6 8. Medical Fitness Form GOVERNMENT OF SINDH NATIONAL INSTITUTE OF CHILD HEALTH, KARACHI Name: MEDICAL/PHYSICAL FITNESS FORM (To be filled by the Examining Physician) Age: Past History: S. No Diseases Year Diagnosis Treated by Present Situation 1. Heart Disease 2. Tuberclosis 3. Communicable 4. Psychoneurosis 5. Physical Disabilities 6. Epilepsy Immunization History: Statues BCG Polio DPT Hep B MMR Mention Status Physical Examination: Height Weight BP Pulse Respiration Eyes Rt Corr. to Hearing Rt Lt Corr. to Lt Skin: Abdomin: Heart: Summary of ECG: Lungs: Summary of Chest X-Ray: Urine Analysis Blood Menstrual Cycle Physical Appearance Hb Regular Sp. Gravity RBC Irregular Albumin WBC Dysmenorrhea Sugar Differential Does it Cells Any other factor not listed above: interfere with work State any treatment or check-up required periodically 6 Physician s Signature Name & Designation with Stamp

7 9. Undertaking/Declaration: UNDER TAKING I Mr./Ms/Mrs S/o,D/o,W/o hereby declare that if selected I will abide by the rules and regulations enforce at present that may hereafter be made by the authorities concerned and undertake that throughout the training period. I will nothing either inside or outside the school premises will interfere with its administration and discipline. In case I failed to do so at any stage I will be liable for any action that the Principal of the school deems fit. I hereby declare that the facts stated above are correct to the best of my knowledge and belief. Dated:- Signature of Applicant DECLARATION I, Father / Husband / Guardian of Mr./Ms/Mrs do hereby declare that the above statement / particulars are true and that my son/daughter/wife is seeking admission in the Diploma in Pediatric Nursing(One Year Post Basic Specialized Diploma Course) with my consent. I hereby undertake that my son/daughter / wife will abide by the rules of this Institution. In case he/she fails to do so at any stage he/she will render himself/herself liable for any action that the Principal of the school deems fit according to the provision of relevant rules. Dated:- Signature Father /Mother/Husband/Guardian Name of Father/Mother//Husband/Guardian: Address: CNIC No: Validity Date Contact No(Landline): Cell No: 7

8 ACKNOWLEDGEMENT/ADMIT CARD Photo GOVERNMENT OF SINDH NATIONAL INSTITUTE OF CHILD HEALTH KARACHI Diploma in Pediatric Nursing (One Year Post Basic Specialized Diploma Course) Roll No. Date: Name of Candidate: Father/ Husband s/ Guardian Name Date of Test/Interview Session Candidates must bring their original documents, CNIC, PNC Registration Card and Admit Card to be appeared in the written test/interview. Signature of Admin Officer ACKNOWLEDGEMENT/ADMIT CARD Photo GOVERNMENT OF SINDH NATIONAL INSTITUTE OF CHILD HEALTH KARACHI Diploma in Pediatric Nursing (One Year Post Basic Specialized Diploma Course) Roll No. Date: Name of Candidate: Father/ Husband s/ Guardian Name Date of Test/Interview Session Candidates must bring their original documents, CNIC, PNC Registration Card and Admit Card to be appeared in the written test/interview. 8 Signature of Admin Officer

9 How to submit application form:- Please fill the Application Form properly with complete and correct information/ answers. Please do not leave any field blank, otherwise your application may not be considered. Attach your Original Bank Deposit Slip (CTS Copy). Application Fee (Service Charges) is non-refundable/non-transferable. Candidate s Signature HELP LINE info@cts.org.pk Please Submit Application BY HAND to School of Nursing National Institute of Child Health H.J Shaheed Road Karachi Ph Ext.282 9

10 Candidates Testing Services Pakistan NATIONAL INSTITUTE OF CHILD HEALTH Branch Name: Branch Code : Date: ONLINE DEPOSITE SLIP (* Please deposit fee any MCB Bank Ltd online branch) MCB Bank Ltd Bank Copy Applicant's Name: Father s Name: CNIC No/ B Form No: Post Name: Remote Branch : F-6 Markaz Super Market Islamabad A/C Title : Candidates Testing Services A/c No: ( Note: Desired Bank Stamp is required on the Deposit Slip) ( Note : No Bank Charges) Test Processing Fees Amount Rs: 193/- + GST Rs.32/-=Rs.225/- Amount in words: Two-Hundred Twenty-Five Rupees Only (Non Refundable/ Non Transferable) Applicant Signature Cashier Officer The receipt of cash/cheque/instrument by the bank evidenced through this deposit slip will be valid only when this deposit slip has been signed and stamped by an authorized officer of the Bank. Candidates Testing Services Pakistan NATIONAL INSTITUTE OF CHILD HEALTH Branch Name: Branch Code : Date: ONLINE DEPOSITE SLIP (* Please deposit fee any MCB Bank Ltd online branch) CTS Copy MCB Bank Ltd Applicant's Name: Father s Name: CNIC No/ B Form No: Post Name: Remote Branch : F-6 Markaz Super Market Islamabad A/C Title : Candidates Testing Services A/c No: ( Note: Desired Bank Stamp is required on the Deposit Slip) Note : No Bank Charges) Test Processing Fees Amount Rs: 193/- + GST Rs.32/-=Rs.225/- Amount in words: Two-Hundred Twenty-Five Rupees Only (Non Refundable/ Non Transferable) Applicant Signature Cashier Officer The receipt of cash/cheque/instrument by the bank evidenced through this deposit slip will be valid only when this deposit slip has been signed and stamped by an authorized officer of the Bank. Candidates Testing Services Pakistan NATIONAL INSTITUTE OF CHILD HEALTH Branch Name: Branch Code : Date: ONLINE DEPOSITE SLIP (* Please deposit fee any MCB Bank Ltd online branch) Applicant s Copy MCB Bank Ltd Applicant's Name: Father s Name: CNIC No/ B Form No: Post Name: Remote Branch : F-6 Markaz Super Market Islamabad A/C Title : Candidates Testing Services A/c No: ( Note: Desired Bank Stamp is required on the Deposit Slip) Note : No Bank Charges) Test Processing Fees Amount Rs: 193/- + GST Rs.32/-=Rs.225/- Amount in words: Two-Hundred Twenty-Five Rupees Only (Non Refundable/ Non Transferable) Applicant Signature Cashier Officer The receipt of cash/cheque/instrument by the bank evidenced through this deposit slip will be valid only when this deposit slip has been signed and stamped by an authorized officer of the Bank. 10