apls photos

Advancing care through excellence in

education

 

Generic Instructor Course (GIC)

Application form + online payment

(All * marks are mandatory)

 

 

 

 

 


Full name (this is how you wish your name to appear on your course certificate)

Title * Please select an item.
Forename(s) * A value is required.
Surname * A value is required.


Name that you are known/called by (this will go on your ID Badge)

Name * A value is required.


Personal Details

Address Line 1 * A value is required.
Address Line 2
Address Line 3
Town / City * A value is required.
Postcode * A value is required.
Country * A value is required.
Mobile Number * A value is required.
Work Number
Ext-Bleep Ext: Bleep:
Email * A value is required.Invalid format.
Special Physical Needs * [Type No, if you have no special needs] A value is required.
Special Dietary Needs * [i.e. Gluten free, Any allergy, Halal, No Beef, No Pork etc.
Type No, if you have no special dietary
needs]
A value is required.


Professional Details

Job Title * Please select an item.
Speciality * Please select an item.
GMC/NMC/HPC Number
(UK applicants only) *
[Type N/A if you are not UK Applicant]
A value is required.
Which NHS Health Board or NHS Trust do you work in?*
Please make a selection.
Name of Hospital or Institution * A value is required.
Address of Hospital or Institution *
Address Line 1* A value is required.
Address Line 2
Address Line 3
Town/City* A value is required.
Country* A value is required.
Postcode* A value is required.


Username/Password (For Member Login)

Username * [This must contain a combination of letters and at least one number (0-9)] A value is required.
Password * [Minimum character 8, maximum 12, No special character (&,!,$,%,...) please] A value is required.Minimum number of characters not met.Exceeded maximum number of characters.


Photo Upload (For Course Administration)

Please upload a recent photo of yourself. *
[Please ensure that the photo you are uploading is named in the following format: 'firstname_surname', e.g. if your name is David Jones then name your photo file as David_Jones.jpg, before uploading it. We accept photo files of any of the following formats: gif, jpeg, jpg, pjpeg, x-png, png.]


Provider Course Details

Which provider background are you applying from? Please select an item.
Provider Course centre A value is required.
Provider Course dates From: A value is required. To: A value is required.

 

GIC Course Details

Your selected session



Course Payment

Are you paying your course fee by yourself or is any other trust/organization paying on your behalf? [If you are normally funded by your Health Board, you will need to initially pay the fee yourself, then re-claim the cost from the Health-Board]

Please specify: A value is required.
(e.g. Self / Health Board etc..)

Disclaimer: Any interaction with your Health Board or responsibility for claiming funding support lies solely with you, the candidate, and not with the course organiser.

Privacy & Policy Accepted*
(See our privacy and policy document)
Please make a selection.
Terms & Conditions Accepted*(See our terms and conditions) Please make a selection.