Standard application Form

Date
Received:
Student
Number:
Course
Code:
Cohort
Number:
APPLICATION FORM: Workshops, Level 5 and Level 6 modules
Thank you for choosing to study with Education for Health. As an organisation we are committed to offering high quality
training and education to practitioners providing care to people with long-term conditions. Please complete the
application form below. To enable us to process your form quickly it is important that all sections of the form are
completed fully. Please write legibly.
If you require any further assistance with completing your application form, please contact (01926)493313, or e-mail
[email protected]
Please return your completed form to: Education for Health, The Athenaeum, 10 Church St, Warwick, CV34 4AB
1. PERSONAL DETAILS AND CONTACT INFORMATION
Learning materials for paper-based courses will be sent via a delivery service and will require a signature on arrival.
Delivery of learning materials, results and certificates will be to the address you give here unless you contact us to
specify an alternative. Please ensure that you enter your postcode accurately to ensure safe delivery.
Date of birth:
Title:
Sex: M / F
Which Employer do you work for (CCG, Practice):
First name:
Current job Title:
Surname:
Correspondence address:
Address 1:
PIN number or equivalent:
Address 2:
Previously obtained
Academic Qualifications:
Address 3:
GCSE / O levels or
Equivalent
Town/City:
HNC / HND
Foundation degree
AS levels
First degree
County:
A levels / Baccalaureate
or equivalent
Postgraduate degree
Postcode:
Email:
Daytime telephone number:
Mobile telephone number:
2. COURSE DETAILS
Course Title:
Level:
Workshop
Venue: Warwick
Start date (as advertised):
Attendance date (as advertised):
Level 5
Level 6
Stirling
London
3. FURTHER INFORMATION
This information is to help us plan support services. If you
indicate that you have special needs we will contact you to
discuss any support arrangements.
You do not have a disability
You have dyslexia
You have a visual impairment
You have a hearing impairment
You use a wheelchair/have mobility difficulties
If you have a disability not mentioned above please give
details below:
Please tick the box which most closely describes your
ethnic origin. This information is for statistical purposes
only.
White
Black
Asian
Chinese
Other ethnic origin
Prefer not to say
4. ADDITIONAL RESOURCES
We offer a broad range of educational products that are designed to support your education and training. Find out more
at: www.educationforhealth.org/products
Keep up to date with our FREE eNewsletters relevant to your needs – register online at:
www.educationforhealth.org/newsletter
Where did you
hear about us?
(please tick)
At an event
Received Direct
Marketing
Word of mouth
Trainer
Published article /
Journal
Internet search
5. SUBMITTING YOUR APPLICATION FORM
Please ensure that you read and understand the terms and conditions overleaf, then sign and date your application form
where indicated below and complete the payment information:
DECLARATION:
By signing and dating this form I confirm that to the best of my knowledge, the information that I have given in this
application and any enclosed information is accurate and complete. I agree to the Education for Health terms and
conditions overleaf.
Your signature:
Date:
6. PAYMENT
Module fees are quoted on our website www.educationforhealth.org or please call the main switchboard on (01926) 493313. You
can also find information regarding possible sources of funding for study on our website.
Please indicate your method of payment below:

I enclose a cheque for the total amount made payable to ‘Education for Health’

Please debit my card below with the full amount

Payment of the total amount to be made by bank transfer to Education for Health, sort code 204808, account no.
00201618 (the reference should be the applicant’s name, and a remittance advice must be sent to
[email protected]). Date of bank transfer:________________
The following option is available ONLY if payment will be made no later than 6 weeks before the course start date:

I enclose a purchase order or other confirmation from a third party that has agreed to make payment on my behalf upon
submission of an invoice from Education for Health. (Invoicing details must be included to process your application.)
Please note: The processing of your application may be delayed if payment information is missing or if payment is not
received at least 6 weeks before the course start date.
Payment details:
Card Details:
MasterCard
Visa
Delta
Visa-Debit
Course fee
£
Additional Resources
£
Cardholders Name:
Overseas Postage * (where
£
Address card is registered to (if different to correspondence address given):
(Please note we do not accept American Express cards)
applicable)
Total
£
* Overseas students (including Ireland) please
note: an extra charge will be applied for postage
of course materials: Standard overseas rates
will apply. Please ring Student Support (01926)
838969 for further information.
Postcode:
Card Number:
Expiry date:
3-digit security number:
Applications for courses are processed on a first come first served basis and consequently, in a small number of cases, advertised dates
may not always be available when we receive your application. In this situation we will contact you to discuss alternative arrangements.
Education for Health
Part A: General Terms and Conditions
The General Terms set out in this Part A apply to any application made
by you the student (“You”) to Education for Health (“EFH”) (the
“Application”) irrespective of whether such Application is for a Module or
Workshop (the “Course”). The subsequent Parts B and C set out the
specific terms applicable to Modules and Workshops respectively.
1.
a)
All materials supplied remain the property of EFH until full payment
is received.
c)
Copyright in all materials belongs to EFH and they are supplied on
the condition that they must not be copied or disposed of or
transferred to any other person or party.
d)
EFH has the right to refuse any person admission on, or
continuance with, any Course, at its discretion.
e)
EFH reserves the right to cancel the Course or any activity with the
Course in unavoidable circumstances at which time EFH will, at its
sole discretion, offer alternative dates or a refund.
f)
EFH cannot be held responsible for any costs other than the Course
fee in the event your course is cancelled by EFH.
g)
EFH will make students aware of in advance of the Course:
a.
The delivery format of the Course;
b.
The key date or dates of the Course;
c.
The location of the venue with comprehensive directions;
d.
The relevant facilities provided or made available at the venue.
h)
EFH may postpone, withdraw or restrict a particular Course.
i)
EFH will use your details to obtain Open University certification if
applicable.
j)
a)
Payment
Full payment is due six weeks before the start date of the Course. If
your application is made less than six weeks before such start date
payment is due immediately.
c)
d)
k)
a)
We require You to give us contact information; Name, address,
telephone number, e-mail address, education, training and
employment details.
a)
We will take security measures to protect your personal information
in storage and will only pass this information to external parties to
enable delivery of your learning and to those who provide full or part
sponsorship for your training with information in relation to your
application, attendance and whether there was a successful or
unsuccessful outcome of any training.
b)
We may use this information to keep You up-to-date with new
developments at EFH, unless you mark this box to indicate that You
do not wish us to do this
c)
In accordance with the Data Protection Act (1988), if at any time
You no longer wish to receive information from EFH either by post
or e-mail, or would like to be removed from EFH’s database (this
can not apply to current students), please contact the Data
Controller, Education for Health, 10 Church St, Warwick, CV34 4AB
or e-mail [email protected]
m)
a)
Miscellaneous
This Application and any dispute or claim arising out of or in
connection with it or its subject matter or formation (including noncontractual disputes or claims) shall be governed by and construed
in accordance with the law of England and Wales.
b)
The parties irrevocably agree that the courts of England and Wales
shall have exclusive jurisdiction to settle any dispute or claim that
arises out of or in connection with this agreement or its subject
matter or formation (including non-contractual disputes or claims).
c)
If any of these conditions are held to be invalid or unenforceable,
that they will not affect the validity and enforceability of the rest.
d)
EFH shall not be liable for any failure to perform any or all of its
obligations if the failure (or delay) is due to the actions of someone
else or to any cause beyond its reasonable control.
Your Booking
EFH reserves the right to alter the structure of any of the Course
without prior notice, provided that quality is not affected.
b)
b)
b)
If You are allocated a free or part funded place under a sponsorship
scheme and subsequently fail to attend you will be liable for the
portion of the fee paid by the sponsorship scheme. This amount will
be returned to the sponsorship scheme.
If the Course is being funded by another party other than You and
payment is not received, as per this Agreement EFH will request
payment from You.
If you request alternative dates between Application and six weeks
before start date EFH reserve the right to charge any difference that
may have been generated by a price review during this period.
Courses Delivered Under a Third Party Agreement
If you are attending a Course delivered by EFH under an
agreement with a third party the following differences apply to your
Terms and Conditions:
(i)
(ii)
Course information detailed in section 1g will be confirmed by
third party therefore students will not have up to six weeks
before the Course start date to contact EFH for alternative
dates; and
Any fees relating to resits, resubmissions and reallocations will
be charged to You.
b)
EFH cannot be held responsible for any costs in the event the
Course is cancelled by the third party.
c)
EFH cannot be held responsible for any complaints that are a direct
result of the third party not upholding their signed Terms and
Conditions with EFH.
l)
a)
Data Protection
Both parties acknowledge that, for the purposes of the Data
Protection Act 1998 (the “Act”), EFH is the Data Controller in
respect of your Personal Data and shall act in accordance with the
provisions of the Act.
Part B: Module Terms and Conditions
The specific terms set out in this Part B apply to any Application made by
You to EFH in respect of Modules. The General Terms set out in Part A
apply to, and form and integral part of, these specific terms.
a)
You have up to six weeks before the Module start date to contact
EFH to request alternative dates, after this period your request will
be treated as a reallocation.
b)
If You fail any part of your Module You will be charged an additional
fee for re-sitting or re-submitting the appropriate part.
c)
If you defer from your Module and require re-allocation you will be
charged an additional fee.
d)
The Open University certification fee is included in the Module fee.
This fee is subject to change at any time following price changes by
The Open University.
Part C: Workshop Terms and Conditions
The specific terms set out in this Part C apply to any Application made
from You to EFH in respect of Workshops. The General Terms set out in
Part A apply to, and form and integral part of, these specific terms.
You have up to six weeks before the course date to contact EFH to
request an alternative date, after this period no alternative can be offered.