apls photos

Advancing care through excellence in

education

 

Advanced Life Support e-learning Course

(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.]


Course Details
Your course Please select an item.
Your selected session


Potential Instructorship
If you do well at the course, would you like to be considered for instructorship? Please select an item.


Course Payment
Are you paying your course fee/administration 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* Please make a selection.