Chelsea and Westminter NHS Foundation Trust

Simulation Courses - Application Form

All questions marked with an '*' are mandatory:

Please choose a course date

* Course: Please select a course. Please select a course.
* Course date 1st choice: Please select a date. Please select a course date.
Course date 2nd choice:

Applicant details

* First name: Please enter your First Name
* Surname: Please enter your Surname
* Title: Please select a Title.
* Profession: Please select a Profession.
If Allied Health, please specify:
* Speciality: Please select a Speciality.
* Grade: Please select a Grade.
* Professional Registration: Please select a Registration
* Registration No: Please enter your Reg No
* Department: Please enter your Dept
* Place of Work: Please select a hospitalPlease select a hospital
If OTHER please fill out the name of your hospital
to prevent a delay to your application
Other

Contact details

* Address Line 1: Please enter your full address
* Address Line 2: Please enter your full address
* Address Line 3: Please enter your full address
* Post code: Please enter your full Post Code
* Email: Please enter your emailPlease Enter a Valid Email.
* Confirm Email: Please confirm your emailThe values don't match.
* Phone Mobile: Please enter your Phone Number
Phone Work:

Are you an instructor on any of the courses?

ALS APLS ATLS
GIC NLS Simulation  

Please authorise your application.

* I authorise that the above provided information is correct and accept that my information will be stored on a database for the purposes of administration and registration of the course. I also agree to hold confidential all information relating to the candidates taking part on this course; their identity, performance and any personal disclosures they may have given during debriefing. I give my consent for any recordings made during this course that contains my image to be used for debriefing and archived for the purposes of research and/or course development.

All cancellations are subject to £50 administration fees if cancelled more than 4 weeks before the course. No refunds will be made for non-attendance or for cancellation with less than 4 weeks' notice prior to the course. Internal candidates will be personally invoiced the full amount of the course for not attending.

Note: During simulation courses, a recording of each scenario will be made to facilitate debriefing sessions. These recordings will be stored securely for no more than 1 year.