APPLICATION FORM
Application for a place on the following course:
- Introductory Certificate in First Line Management (Cost = £460.00)
- Managing Health & Social Care Certificate (Cost = £1,350.00)
- Postgraduate Diploma in Managing Health & Social Care (£2,550.00)*
1. This section to be completed by the applicant.
NAME:……………………………………..............……………………………DR/MR/MRS/MISS/MS…………….
SIGNATURE:……………………………………..............………………………………………………..…………….
DESIGNATION:…………………………………..............…………………………………………………..………….
LOCATION:…………………………………………..............………………………………………………...…….…..
EMPLOYING ORGANISATION:…………………..............………………………………….………………...……..
TELEPHONE NO:………………………………..............………………… FAX NO:…………………………....….
ADDRESS TO SEND INVOICE: ………………................………………………………………………..………....
………………………………………………………..............…………………………………………………………...
………………………………………………………..............…………………………………………………………...
2. If applying for the Health & Social Care Certificate this section to be completed by applicant's manager:
I confirm that I support the application of the above-mentioned person. I also understand that I am required to attend the morning of the Introduction Day. For candidates undertaking the Project route, I understand that I will be required to give additional support in the workplace in order to help the candidate identify an appropriate Project and to provide practical support to assist the candidates completing the project.
NAME:…………………..................…………………………………………… DR/MR/MRS/MISS/MS…………….
SIGNATURE:…………………………....................…………….……………………………………………………….
DESIGNATION:………………………………………..................……………………………………………………….
3. PAYMENT
On receipt of your Registration Form, we will invoice your employing organisation nearer the actual date. No cheques are required with this form.
4. CONDITIONS FOR CANCELLATION PLEASE RETURN COMPLETED FORM TO:
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Cancellations made prior to 28 days before the event commences will incur an administration charge of 15% of the full cost.
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In the event of a cancellation made within 28 days, you/your Trust/ Health Authority/ Organisation will be held liable for the full cost.
5. PLEASE RETURN COMPLETED FORM TO:
Eileen Brennan, Programme Administrator, Business Development Consultancy, West Heath Hospital, Rednal Road, West Heath, Birmingham B38 8HR
Tel: 0121 465 7850 Fax: 0121 465 7857
ALTERNATELY, RETURN VIA EMAIL TO:
* -Year one fee is £1,600 and year two fee is £950.