Student Application & Consent Form - MEDICAL EDUCATION at ...

Other Relevant InformationSchool/College Tutor referenceTutor’s Name………………………………………………………………………..School/College Address ……………………………………………………..………………………………………………………………….Postcode………………Telephone Number ………………………….…..…………………………………Email……………………………………………………………………………...….Do you support this applicant’s request for the Anatomy Academy one dayprogram? (please circle)YesNoIf you wish to add any comments in support of this students applicationplease do in the space provided………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….………………………………………………………………………………………………………….

Student applicationPlease ensure you answer the following questions as fully as possible:1. Why have you chosen to do your additional learning in the NHS?________________________________________________________________________________________________________________________________________________________________________________________________________________________2. How many professions do you think there are in the NHS?Which ones do you know about?________________________________________________________________________________________________________________________________________________________________________________________________________________________3. What are your learning objectives for the Anatomy program?What would you like to take away?________________________________________________________________________________________________________________________________________________________________________________________________________________________4. The NHS is the largest employer in EuropeWhy do you think this is?________________________________________________________________________________________________________________________________________________________________________________________________________________________5. List any NHS Government Targets which are to be achieved over thenext two years?________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please use this space to provide information in support of your application(continue on a separate sheet if necessary):I wish to be considered as a candidate for the Anatomy Academy programbecause________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If you have any special needs/requirements please could you providedetails of areas where we may be able to offer support to ensure yourplacement on the course is successful. This will not affect your applicationbut will help us to arrange any support/equipment you may require:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________NB: All information provided above will be treated in the strictest confidenceand will only be viewed by those members of Trust staff with a genuine reasonto access this information.

Student, Parent and Teacher Agreement to Trustrequirements1. The Trust places considerable importance on the need for attention toHealth and Safety at work. You have the responsibility to acquaint yourselfwith the safety rules of the work place, to follow these rules and make use offacilities and equipment provided for your safety. It is essential that allaccidents, however minor, are reported.2. The Trust will also expect you to observe other rules and regulationsgoverning the workplace which are drawn to your attention. Please note thatthere is a No Smoking Policy covering the whole hospital environment andthat there are securtiy arrangements applicable to most locations.3. The Trust fully supports equal opportunities in education and employment.The Trust opposes all forms of unlawful or unfair discrimination on thegrounds of ethnic origins, gender, disability, age, religion or sexuality.4. There will be a £20 charge per student to attend the one day program.All monies to be collected by School/College tutor prior to commencement ofthe course. This will cover administration and tuition fees.A £5 meal voucher will be provided which will be redeemable in the hospitalcanteen. Students are invited to bring any additional snacks/drinks if required.I have read and understood the above requirements.Signed (student): _________________________ Date:_________________Signed (School/College Tutor) _________________ Date: _______________Please obtain the following signatures: (under 18yrs.)Parent/GuardianI have read the programme information and understood the requirements. Iwill ensure the student carries out these obligations and confirm that he/she isnot suffering from any complaint, which might create a hazard to him/her or tothose learning with him/her. I give permission for my son/daughterto attend the course and participate in outlined activities during his/her visit tothe University Hospitals Coventry and Warwickshire NHS Trust.Signature:Date: ________________