Application for Anatomy Academy Program

Transcription

1 Application for Anatomy Academy Program All students please complete this application form to secure your place. Information will be treated in the strictest confidence. Once completed please hand this form to your head of year at least 3 weeks prior to course commencement. Student Personal Details Title: Surname: Forenames: Address for Correspondence: Postcode: Telephone no: Date of Birth: Address: School/College: Address: Careers Advisor: Tel no: Next of Kin: Daytime Tel no: Emergency Contact Name: Emergency Contact Tel no: Student Health Have you any health problems which you feel University Hospitals Coventry and Warwickshire NHS Trust should be aware of prior to your visit? If so please give details:

2 Other Relevant Information School/College Tutor reference Tutor s Name.. School/College Address...Postcode Telephone Number Do you support this applicant s request for the Anatomy Academy one day program? (please circle) Yes No If you wish to add any comments in support of this students application please do in the space provided

3 Student application Please ensure you answer the following questions as fully as possible: 1. Why have you chosen to do your additional learning in the NHS? 2. How many professions do you think there are in the NHS? Which ones do you know about? 3. What are your learning objectives for the Anatomy program? What would you like to take away? 4. The NHS is the largest employer in Europe Why do you think this is? 5. List any NHS Government Targets which are to be achieved over the next two years?

4 Please use this space to provide information in support of your application (continue on a separate sheet if necessary): I wish to be considered as a candidate for the Anatomy Academy program because If you have any special needs/requirements please could you provide details of areas where we may be able to offer support to ensure your placement on the course is successful. This will not affect your application but will help us to arrange any support/equipment you may require: NB: All information provided above will be treated in the strictest confidence and will only be viewed by those members of Trust staff with a genuine reason to access this information.

5 Student, Parent and Teacher Agreement to Trust requirements 1. The Trust places considerable importance on the need for attention to Health and Safety at work. You have the responsibility to acquaint yourself with the safety rules of the work place, to follow these rules and make use of facilities and equipment provided for your safety. It is essential that all accidents, however minor, are reported. 2. The Trust will also expect you to observe other rules and regulations governing the workplace which are drawn to your attention. Please note that there is a No Smoking Policy covering the whole hospital environment and that there are securtiy arrangements applicable to most locations. 3. The Trust fully supports equal opportunities in education and employment. The Trust opposes all forms of unlawful or unfair discrimination on the grounds of ethnic origins, gender, disability, age, religion or sexuality. 4. There will be a 20 charge per student to attend the one day program. All monies to be collected by School/College tutor prior to commencement of the course. This will cover administration and tuition fees. A 5 meal voucher will be provided which will be redeemable in the hospital canteen. Students are invited to bring any additional snacks/drinks if required. I have read and understood the above requirements. Signed (student): Date: Signed (School/College Tutor) Date: Please obtain the following signatures: (under 18yrs.) Parent/Guardian I have read the programme information and understood the requirements. I will ensure the student carries out these obligations and confirm that he/she is not suffering from any complaint, which might create a hazard to him/her or to those learning with him/her. I give permission for my son/daughter to attend the course and participate in outlined activities during his/her visit to the University Hospitals Coventry and Warwickshire NHS Trust. Signature: Date: