UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Application for Admission to the CPD Programme in Paediatric Neuropsychology
(May 2016)
PERSONAL DETAILS (Please complete in black ink and write CLEARLY.)
SURNAME OR FAMILY NAME:
FIRST NAME(S):
TITLE: (Dr, Mrs, Mr, etc)
DATE OF BIRTH (day, month, year)
SEX: M
F
NATIONALITY:
ADDRESS FOR CORRESPONDENCE:
TELEPHONE NUMBER: (daytime)
E-MAIL ADDRESS:
Title and Dates
CPD COURSE 1: Introduction to Developmental Cognitive
Neuroscience
3-7 October 2016
CPD COURSE 2: Professional Issues for Paediatric
Neuropsychologists
10-14 October 2016
CPD COURSE 3: Development of Sensory, Motor and Cognitive
Neural Systems.
28 November- 2 December 2016
PLEASE CIRCLE OR HIGHLIGHT THE BOXES
BELOW TO INDICATE WHICH COURSES
YOU WISH TO REGISTER FOR
Early Bird Rate
Standard Rate
Closing date
22 August 2016
Closing date
15 September 2016
£973
£833
Closing date
29 August 2016
Closing date
26 September 2016
£833
£973
Closing date
31 October 2016
Closing date
21 November 2016
£833
£973
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UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
CPD COURSE 4: Developmental Disorders and
Neuropsychological Profiles
Early Bird Rate
Standard Rate
Closing date
19 December 2016
Closing date
6 January 2017
£833
£973
Closing date
6 January 2017
Closing date
27 January 2017
£833
Closing date
13 February 2017
£973
Closing date
27 February 2017
£833
£973
Closing date
24 March 2017
Closing date
17 April 2017
£833
£973
2 course Early bird
rate
2 course Standard
rate
£1,386
£1,750
9-13 January 2017
CPD COURSE 5: Infant and Neurodevelopmental Assessment
6-10 February 2017
CPD COURSE 6: Assessment of neuropsychological profiles and
their functional implications
13-17 March 2017
CPD COURSE 7: Advanced Developmental Cognitive
Neuroscience
24-28 April 2017
TWO CPD COURSES– Special Offer
Please mark the two courses you wish to attend above and then
circle the price to the right.
The closing date is the earliest closing date of the two courses
above.
PAYMENT OPTIONS
Please choose an option and fill in the details for that option
CUSTOMER INVOICE DETAILS (Please note lines with * must be completed)
Customer contact name*
___________________________________________________________________
Customer name*
___________________________________________________________________
Billing address* ___________________________________________________________________
Contact telephone number* ______________________________________________________________
Email address *
___________________________________________________________________
Web address* ___________________________________________________________________
Customer reference/PO
___________________________________________________________________
Customer registration number ___________________________________________________________________
VAT number*
___________________________________________________________________
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UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Accounts Payable Contact Telephone Number* ______________________________________________
Accounts Payable email address* _________________________________________________________
CHEQUES
Please make cheques payable to ‘UCL’ or ‘University College London’.
BACS
Please contact course administrator for details paed-neuropsych@ucl.ac.uk
EMPLOYMENT
List your employment to date. Please continue on a separate sheet if necessary. You may include a copy of your
curriculum vitae if this is more convenient.
Name and address of Employer
State Country if outside UK
Dates
Position Held and Main Duties
KNOWLEDGE OF PROGRAMME
Where did you find out about this programme?
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------APPLICANT’S DECLARATION
1. I have noted that as a CPD student I will not be an enrolled UCL student and I will NOT have access to
electronic journals or other library resources remotely away from UCL libraries due to UCL policies.
While on UCL premises I will have access to electronic resources, journals, computer rooms and
printers and be able to pay for use of the photocopy machines.
2. I am aware that this course is not credit bearing.
3. Data Protection Act 1988: I agree to ICH/UCL processing personal data contained on this form, or
other data which ICH may obtain from me or other people or organisations whilst I am applying for
admission. I agree to the processing of such data for any purpose connected with my studies, or my
health and safety whilst on ICH premises or for any other legitimate purpose.
Signature
Date
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UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Please return this form to:
Programme Administrator
MSc Paediatric Neuropsychology
Institute of Child Health,
30 Guilford St,
London WC1N 1EH, UK
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