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									FACULTY OF HEALTH AND SOCIAL CARE SCIENCES

                                    Postgraduate application form – 2012/13 entry

This form is for use with the following programmes only:

MSc Advanced Practice
MRes Clinical Practice
MSc Exercise for Health
MSc Health Education and Clinical Leadership
MSc Maternal and Child Health
MSc Rehabilitation
MSc Oncology Practice / Breast Evaluation/ Medical Imaging

This form is intended to provide us with information to ensure a good match between the course and its participants. You
must complete each section as fully as possible. Please read the guidance notes for details of the entry requirements
and admissions procedure.

Course applied for (Please tick route you wish to apply for) †

        MSc/MA (please specify)

        Postgraduate Diploma (PgDip) (please specify)

        Postgraduate Certificate (PgCert) (please specify)†

        Standalone module (please specify)

Mode of study (please tick):              Part time                      Fu l l tim e

 PERSONAL DETAILS


Family name…………………….. ………………First name(s)…………………………………Title (e.g. Miss/Mrs/Mr)……………


Date of birth………………………………..Gender (male/female)……………………Nationality……………………………………

Previous family name (if applicable)……………………………………………………………………………………………………...

Country of birth………………………………….Country of permanent residence………………………………………………........

Please provide date of entry to live permanently (indefinite leave to remain) in EU/UK……………………………………………

Have you entered the UK on a Visa?                 Yes          No

Type of visa (e.g. work, student, dependents)…………………………………………………………………………………….........

Contact address (Home address preferable)……………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………Post code………………………………………………………

Tel No (Home)…………………………………………………………..Fax No…………………………………………………………

Tel No (Work)…………………………................................................Mobile Tel No………………………………………………...

Email address (must accept automated emails)………………………………………………………………………………………..
   PROFESSIONAL EDUCATION

Please give details of your professional qualifications. If results are expected, please indicate when the results are
expected to arrive


Professional body Registration number Date                                      Expiry                   Qualification obtained                                Year
                                      joined                                    date                                                                           obtained




Please give details of any other courses or academic achievements not already mentioned which might help your
application

 ACADEMIC RECORD

Please list all colleges and universities attended, giving dates of course, title and result of qualification. Please list all
of your qualifications including GCSE/O Level; A Level; University Diploma and Degrees (and other qualifications if
appropriate). List your qualifications in chronological order beginning with your most recent qualifications. If you do not
have a first degree or equivalent, please provide details of any other relevant qualifications or experience which you feel
would be relevant. (Continue on a separate sheet if necessary)

         College/University                                Course title and award                                          From – To                      Result (including
                                                                                                                                                          degree
                                                                                                                                                          classification)




 ENGLISH LANGUAGE

Is your first language English? (Please tick)                      Yes                       No

If you ticked no please complete the following questions

Did you study at school/university where you were taught in English?                                     Yes                     No

If yes, for how many years.........................................................................................................................................................

If English is not your first language have you taken an En glish language examination? Yes                                                               No

If yes, please give details of the testing system (name and address e.g. IELTS) and attach the relevant certificate to this
application

……………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………….......

……………………………………………………………………………………………………………………………………………...


Date of issue……………………………………………………Overall score…………………………………………………...........
 EMPLOYMENT AND WORK EXPERIENCE

Please list most recent first and work backwards - Please account for any absences from employment

 Name of organisation                Address (town, country)         Position held              From - To




PRACTICE INFORMATION (MSc Advanced Practice and MSc Health Care only)


 Practice mentor

 Please provide details of a suitable mentor who will support you in your studies

 Family name …………………………...First name(s)………………………………Title (e.g. Miss/Mrs/Mr)…………………….

 Position held/nature of relationship…………………………………………………………………………………………………

 Contact address………………………………………………………………………………………………………………………...

 ……………………………………………………………………………………………………………………………………………


 …………………………………………………………………………………..Post code……………………………………………

 Email address…………………………………………………………………Tel No………………………………………………...

 NMC Qualified Mentor?                         Yes                                      No

 Audit in practice

 We need to know details about practice audits carried out in your area of work, therefore we would be grateful if you
 could supply us with the following:

 Trust………………………………………………………..Clinical area/Ward………………………………………………………

 Date of last audit………………………………………….Organisation carrying out audit………………………………………
STATEMENT BY APPLICANT


Please write in your own words
   your reasons for applying for this programme,
   give a brief description of your clinical experience to date (if applicable),
   a description of your current responsibilities, role, and its development,
   how you will benefit from this programme at this time,
   how the programme fits in with your career plan over the next 5 years
   please give any further information in support of your application
 SPONSORSHIP AND FUNDING


 Who is paying for this course? (Please tick)
 Self         (if self-funding please continue to the next section – declaration)


 Employer (invoice)              Employer (CPPD Contract)                  Other sponsor


 Employer /sponsor details

 Name…………………………………………………………………………………………………………………………………..

 Postion held…………………………………………………………………………………………………………………………...

 Address of employer/ NHS Trust…………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………..

 ……………………………………………………………………….Post Code……………………………………………………..

 Authorised signatory (Agreement to pay fees) ………………………………………………………………………………………….

 CPPD Contract only

 All applications sponsored via the NHS London CPPD contract must be signed by the designated signatory for the Trust

 Trust NHS Contract Code ………………………………………………………………………………………………………………...

 Signature of Senior Manager in support of application …………………………....................... Date………………………………..

 Designated signatory ……………………………………………………………………………. Date………………………………..


 DECLARATION (TO BE COMPLETED BY ALL APPLICANTS)

I agree that the fees relating to this programme of study will be paid by the person or organisation indicated in the above
section. If for any reason the organisation or person indicated does not pay I will be liable for the fees.


I confirm that the information that I have provided is accurate true and may be verified on request by the University. I
consent for the University to share my results, attendance and academic performance with my sponsoring employer.

Name…………………………………………………………………………………………………………………………………………….

Signature……………………………………………………………………………………………………………………………………..

Date………………………………………………………………………………………………………………………………………

Under the Data Protection Act 1998, the information you supply will be held in strict confidence for the purpose of
ascertaining your suitability for your chosen course of study. In the event that you become a registered student with the
University your data will form the basis of your student record.


Do you have any criminal convictions?                             Yes                      No
 EQUAL OPPORTUNITY MONITORING FORM


The completion of this form is voluntary, but the information it contains helps us to monitor and improve our equal
opportunities policies and procedures. This sheet is removed from the application form before the short-listing
process, thus ensuring that all short-listing is based on merit.

      Ethnic Origin                                  Disability (please tick any that apply)
      White - British                                No disability
      White - Irish                                  Specific learning difficulty (for example, dyslexia)

      Other White Background                         Blind or partially sighted
      Black or Black British - Caribbean             Deaf or hearing impairment
      Black or Black British - African               Wheelchair user or mobility difficulty
      Other Black Background                         Personal care support
      Asian or Asian British - Indian                Autistic Spectrum Disorder or Asperger Syndrome

      Asian or Asian British - Pakistani             Mental health difficulty
      Asian or Asian British - Bangladeshi           Unseen disability e.g. diabetes, epilepsy

      Chinese                                        Other, please specify below
      Other Asian Background                         …………………………………………………………….
      Mixed-White and Black Caribbean

      Mixed-White and Black African

      Mixed-White and Asian
      Other Mixed Background
      Other Ethnic Background
      Not Known
      Prefer not to say


 CONTACT DETAILS

   MSc Health Education and Clinical Leadership / MSc Oncology Practice / Breast Evaluation / Medical Imaging
   Faculty of Health and Social Care Sciences
   Postgraduate Office, Room 6002, Kingston University
   Kingston Hill
   KT2 7LB
   Telephone: 020 8417 5752        Email: postgrad@sgul.kingston.ac.uk

   Advanced Practice, Maternal and Child Health, Rehabilitation, MRes Clinical Practice
   Postgraduate Admissions Officer
   Admissions, Registry
   St George’s, University of London
   Cranmer Terrace
   London SW17 0RE
   Telephone: 020 8725 2333 Email: enquiries@sgul.ac.uk

   MSc Exercise for Health, Faculty of Health and Social Care Sciences
   Postgraduate Office
             nd
   Room 16, 2 floor, Grosvenor Wing
   St George’s, University of London
   Cranmer Terrace
   London, SW17 0RE
   Telephone: 020 8725 2242 Email: postgrad@sgul.kingston.ac.uk

								
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