Course Booking Form Personal DetailsTitle(Required)Forename(Required)Surname(Required)Contact number(Required)Email address(Required) RCUK LMS Email address if different Professional Registration Governing Body(Required)Please choose...GMCNMCHCPCOtherRegistration status(Required)Please choose...FullProvisionalProfessional Registration Number(Required)Other Professional Registration Governing Body(Required)Professional Registration Number other(Required)Current Job Title/Speciality(Required)Grade(Required)Employer Name(Required)Please upload a photo which will be used on the day for our instructors to identify you(Required) Drop files here or Select files Accepted file types: jpg, jpeg, png, heic, gif, bmp, webp, heif, Max. file size: 10 MB, Max. files: 1. AddressThis will be used to post your manual to youAddress(Required) First line of address City/Town County / State / Region Postcode Course detailsPlease select the course(s) you are registering for. You should not attend a course if you are coming off, in-between, or going onto a night shiftFirst course(Required)Please chooseeALS (1 day)ALS Recertification (1 day)EPALS (2 days)EPALS Recertification (1 day)eILS (1/2 day)ILS (1 day)ePILS (1/2 day)PILS (1 day)First course date(Required) DD slash MM slash YYYY To be eligible your new course, the date must be within 12 months of your certificate expiring (12 months before or after expiry date). Please attach your most recent RCUK certificate for verification.Upload first course certificate(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, heic, Max. file size: 10 MB. Add second course Add another course and dateSecond coursePlease chooseeALS (1 day)ALS Recertification (1 day)EPALS (2 days)EPALS Recertification (1 day)eILS (1/2 day)ILS (1 day)ePILS (1/2 day)PILS (1 day)Second course date DD slash MM slash YYYY To be eligible your new course, the date must be within 12 months of your certificate expiring (12 months before or after expiry date). Please attach your most recent RCUK certificate for verification.Upload second course certificate Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, heic, Max. file size: 10 MB. RCUK regulations(Required) I acknowledge the RCUK regulations In line with RCUK regulations the preparation period for your course should be a minimum of 4 weeks. I hereby acknowledge I will have less preparation time if my course booking is made within the 4 week window and give my consent I am willing to attend the course at short notice.Please advise if there is anything else we may need to know before you attend any of the courses e.g any additional learning/exam supportPlease confirm dietary requirements (if any) Vegetarian Vegan Halal Kosher Coeliac Other Other dietary requirementsPlease state any food allergiesPayment InformationPlease select your method of payment(Required)Please choose...Self funding (BACS or Credit Card)Employer fundingPlease complete the following information and we will send your employer an authorisation form and invoice to complete payment.Has the course date leave been approved by your employer(Required)Please choose...YesNoContact name who authorised funding:(Required)Contact email who authorised funding:(Required) Job title of who authorised funding(Required)If Finance department information is known, please complete the details below:Finance department contact nameFinance department email address Further informationHow did you hear about us?(Required) Web search Recommendation RCUK website Previously attended NES course Social media Other Other way you heard about us(Required)I hereby give my consent to processing of my personal details in accordance with the Data Protection Act 2018, EU GDPR 2018, and for audit purposes(Required) Yes I agree to the Terms and Conditions received with the registration form link(Required) Yes Terms and Condition can also be viewed here and highlight clause 2.3, 4.9, 5.1, 5.2 and 5.3 for your attention.Please sign below(Required)Form submission date(Required) DD slash MM slash YYYY
