DIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY APPLICATION FORM FOR ADMISSION IN Jan 2017 Please complete clearly in BLACK ink Use the information on the website to ensure that you complete this form correctly DATE RECEIVED APPLICATION No 1 PERSONAL DETAILS Title Date of Birth Surname/Family Name First/Given Name(s) Postal Address County Postcode Telephone numbers (including STD code) Home Mobile Email Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) national? If no, please give details of the category that relates to your current immigration status. This status will be subject to checking before interview. Does your visa have a condition restricting employment or occupation in the UK? Do you require any special access or educational needs and require any reasonable adjustments to be made during the recruitment process, including interview? If yes, please give details 1
2 EMPLOYMENT HISTORY Names & Addresses of recent employers From To Nature of work Month Year Month Year 3 SECONDARY, FURTHER & HIGHER EDUCATION HISTORY Establishments Attended From To Month Year Month Year FT/PT 2
4 QUALIFICATIONS - awarded Examinations or Assessments for which RESULTS ARE KNOWN, including those failed (including Key/Core Skills) ALL SECTIONS MUST BE COMPLETED see example below Month Year Awarding Body Subject / Unit / Module / Component 06 2010 Open College Access to H.E. Network Science Level / Qualification Level 3 Level 3 Level 2 Result: Grade/Mark/Band/Credits 20 credits Distinction 25 credits Merit 18 credits Use a continuation sheet if necessary Ensure that evidence of all the above qualifications (in the form of COPY CERTIFICATES ) are included with this application. Without these, your application will not be processed. ORIGINAL CERTIFICATES MUST be available to the school if you are called for interview. 3
4 QUALIFICATIONS - not yet awarded Examinations or Assessments for which RESULTS ARE NOT KNOWN OR NOT YET COMPLETED (including Key/Core Skills) ALL SECTIONS MUST BE COMPLETED Month Year Awarding Body Subject / Unit / Module / Component Level / Qualification Expected/predicted Result: Grade/Mark/Band/Credits Use a continuation sheet if necessary ONCE RESULTS ARE KNOWN, IT IS THE APPLICANTS RESPONSIBILITY TO ADVISE THE SCHOOL OF THE RESULTS 5 REGISTRATION are you registered with the General Dental Council If so, what is your registration number: Are you currently the subject of a fitness to practise investigation? If yes, please give details Have you been removed from the register or have conditions been made on your registration? If yes, please give details 6 IMMUNISATION STATUS Evidence of effective immunisation (sero-conversion) Hep B attached Hep B sero conversion attached TB attached 4
7 MONITORING INFORMATION Criminal Convictions Rehabilitation of Offenders Act 1974 The Rehabilitation of Offenders Act helps rehabilitated ex-offenders by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become "spent". During the rehabilitation period, convictions are referred to as "unspent" convictions and must be declared. Before you can be considered for registration with the General Dental Council, the school needs to be satisfied about your character and suitability. Have you any unspent criminal convictions or bind-overs, or any cautions, warnings or reprimands? If yes, you must give details below: - As you are applying for a training place involving access to persons in receipt of health services, your offer of a place is subject to a satisfactory disclosure from the Disclosure and Barring Service (formerly known as CRB). Failure to reveal information relating to any convictions could lead to withdrawal of an offer of a place on the course. Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 In order to protect certain vulnerable groups within society, there are a number of training places within the NHS that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include positions where there is access to patients in the course of school duties. As the training place you are applying for falls within this category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants for such places are not entitled to withhold any information about convictions, cautions, warnings and reprimands which for other purposes are "spent" under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential and will be considered only in relation to places to which the Order applies. A check will be made with the Disclosure and Barring Service. The school aims to promote equality of opportunity and is committed to treating all applicants for places, fairly and on merit regardless of race, gender, marital status, religion or belief, disability, sexual orientation and age. The school undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Have you at any time received or had pending a criminal conviction, caution, warning, reprimand or bind-over? If so, you must give details below: - Does your name appear on the Protection Children Act List? Does your name appear on the Protection of Vulnerable Adults List? 8 NO SMOKING STATEMENT: Students are prohibited from smoking whilst on duty, whilst on School or Trust premises, or whilst representing the School in any capacity. 5
9 SUPPORTING INFORMATION Personal Statement Your personal statement should be no longer than 750 words and MUST be word processed. Applications with handwritten statements WILL NOT BE PROCESSED Please ensure that the word count box is completed. 6
9 SUPPORTING INFORMATION cont d Personal Statement cont d State word count: 7
10 REFERENCES * Do not use family members or someone living in the same household as you Please complete the details below IN FULL. Referee 1 MUST be your employer from your current/most recent post or if you are still in full time education, your tutor. Referee 2 should be someone NOT CONNECTED to your employment, who is able to comment on your personal qualities & abilities. References may be sought at any point from the end of Stage Two of the application process. If you DO NOT wish us to contact your referees until after the interview, please indicate here: The referees can be contacted from the end of stage 2 of the application: Employment / Education Character Referee 1 Referee 2 Name Address Name Address Postcode Tel No Occupation Postcode Tel No Occupation Email Email 11 DECLARATION Signed: I confirm that the information given in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if offered a training place. I have read the online course details and agree to abide by the policies of The Greater Manchester School for Dental Care Professionals if I am admitted to the course. I understand that the offer of a training place will be subject to the course being commissioned by HEE. I also understand that the offer of a training place will be subject to a satisfactory Disclosure & Barring Service; medical screening and reference checks. I consent that the school may, with regard to this application, seek clarification for issues relating to professional registration, employment or qualifications I consent and understand that anonymised information may be given to commissioners for the purpose of education, training and development Dated: 8
12 EQUAL OPPORTUNITIES STATEMENT: NHS organisations recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community. I would describe my ethnic origin as: - Gender A White British Male B White Irish Female C White any other White background D Mixed White and Black Caribbean Disability E Mixed White and Black African Do you consider yourself to have a disability? F Mixed White and Asian G Mixed any other mixed background Do you have: H Asian or British Asian Indian - A visual impairment J Asian or British Asian Pakistani - A hearing impairment K Asian or British Asian Bangladeshi - Special access needs L Asian or British Asian any other Asian background - Special education needs M Black or Black British Caribbean - Other N Black or Black British African P Black or Black British any other Black background R Other ethnic groups: Chinese S Other ethnic groups any other ethnic group If yes, please provide further details If you have a disability which may require reasonable adjustments during the interview process, please advise here: e.g. latex allergy This information is purely for education, training & development purposes and will not be used as part of the selection process 9