Evidence Based Practice Nursing

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School of Community and Health Sciences

Application Form for Study Day/Short Course
Self Funding, Employer Funded and Non NHS London Trust Sponsored 1. Study Day(s)/Short Course(s) Information Course Ref No 1 2 3 Course Title Preferred Date* Please complete this form using black ink, write neatly and clearly in order for us to process it promptly. All sections must be completed.

NM S002

Venepuncture and Cannulation

*We will endeavour to provide a place on the requested date. Should this not be possible, you will be offered an alternative date. Please note: If you are Self Funding please tick this box o 2. Personal Information Title Ms Mr/Miss/Mrs/Ms/Dr/Other .................. Previous Name(s) (if changed) First Name Margaret

Surname
Boyle

Date of Birth

Student Number (if Known)

D D/M M/Y Y Y Y 13/03/1965
Home Address ........................................................................... 23 Walford Road ................................................................................................. London .................................................................................................

Tel No. (Home) Tel No. (Work) Tel No. (Mobile)

020 7254 8179 ........................................................................ 020 8525 6047 ......................................... Ext .................... 07957242 308 ........................................................................

................................................................................................. N18 8EF ................................................... Postcode ........................... 3. Present or Most Recent Employment Post Held Speciality Speciality Clinical Nurse Specialist

Personal/Work Email Address m.boyle@stjh.org.uk

Palliative Care

NMC PIN (if registered nurse, midwife or health visitor) 83k0528s Name of Hospital/Practice St Joseph's Hospice

NMC PIN Expiry Date

D D/M2011 Y Y Y 01 01 M/Y

Name of NHS Trust (if applicable)

Full Address Mare Street .............................................................................................................................................................................................................. Hackney .............................................................................................................................................................................................................. E8 4sa ................................................................................................................................. Postcode .......................................................

4. Ordinances and Regulations of City University London
As a student of City University London you undertake to observe and comply with the Ordinances and Regulations of the University and that, to the best of your knowledge, the information provided is correct and complete. Information about City University London’s Ordinances and Regulations is available at: www.city.ac.uk/aboutcity/governance/ordinances_and_regulations

5. Data Protection Act 1998
We are collecting this information to process your application and to support your study at City University London in accordance with the Data Protection Act 1998. We may pass information about your progress to other organisations such as a sponsor. Further details in relation to the use of personal data can be found at www.city.ac.uk/dataprotection If you would like more information or have concerns please contact the Head of Information Compliance and Policy via dataprotection@city.ac.uk

Tel: + 44(0) 20 7040 5799, Fax: +44 (0) 20 7040 5808, Email: healthprofessionals@city.ac.uk CPD Administration Team, School of Community and Health Sciences, City University London, Health Building, Northampton Square, London EC1V 0HB 1

School of Community and Health Sciences

6. Financial Terms and Conditions
All fees are payable in advance of the...
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