ETC Booking Form - The Health Academy

"*" indicates required fields

Name*

Prefix First Last

Preferred badge name*

Email*

Job Title*

Grade*

Speciality*

Healthcare Professional Registration Number*

ie. GMC / NMC / HPC

Primary Contact Number*

Alternative Contact Number

National Training Number*

Work Address*

Please enter your work address that you are currently employed at

Street Address Address Line 2 City County Post Code Country

What is your manager's name?*

If you are a member of medical staff and do not know this information, please enter N/A

What is your manager's email address?*

If you are a member of medical staff and do not know this information, please enter N/A

Please specify any dietary/other requirements for face-to-face training*

If you require any additional support or alternative access on the day, please specify what you will need and a member of the team will contact you to discuss.

Which ETC Course would you like to attend?*

Select the date that you wish to attend*

Date of birth of applicant*

Do you require a car parking voucher?*

We are able to offer course attendees a discount voucher of £3.50 to park onsite, will you be needing one for your vehicle?

How did you hear about this course?*

How do you intend to pay?*

Please indicate if you are receiving any funding for this course and confirm how you wish to pay. Once your application is submitted, a member of the team will be in contact via the email given above to take payment.

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