UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Application for Admission to the Taster 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:

Please note taster courses are limited to Clinical or Educational Psychologists currently registered
with the Health and Care Professions Council (HCPC). Potential Taster candidates should also note
that whilst they are on ICH premises they will have access to electronic resources, journals,
computer rooms and printers and be able to pay for use of the photocopy machines. However, when
working off-site, it is currently NOT possible to access electronic journals remotely.
Title and Dates
TASTER COURSE 1: Introduction to Developmental Cognitive
Neuroscience
3-7 October 2016
TASTER COURSE 2: Professional Issues for Paediatric
Neuropsychologists
10-14 October 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
£933
£1,073
Closing date
29 August 2016
Closing date
26 September 2016
£933
£1,073
UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Early Bird Rate
Closing date
31 October 2016
Standard Rate
Closing date
21 November 2016
£933
£1,073
Closing date
19 December 2016
Closing date
6 January 2017
£933
£1,073
£1,650
£1,995
TASTER COURSE 3: Development of Sensory, Motor and
Cognitive Neural Systems.
28 November- 2 December 2016
TASTER COURSE 4: Developmental Disorders and
Neuropsychological Profiles
9-13 January 2017
ANY TWO TASTER COURSES– Special Offer
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*
___________________________________________________________________
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.
UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
Name and address of Employer
State Country if outside UK
Dates
Position Held and Main Duties
PROFESSIONAL STATUS
Please provide your HCPC registration number
KNOWLEDGE OF PROGRAMME
Where did you find out about this programme?
REFEREES
State the names and addresses of the two people who have provided the references that you are returning with this application. Please ensure
that the letters are confidential. (ie sealed envelopes signed across the seal)
Name
Name
Position
Position
Address
Address
Tel
Email
Fax
Tel
Fax
Email
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------APPLICANT DECLARATION
UCL INSTITUTE OF CHILD HEALTH
In partnership with Great Ormond Street Hospital for Children NHS Trust
1. I understand that taster courses are limited to Clinical or Educational Psychologists currently registered
with the HCPC and I have provided my registration number.
2. I have noted that as a taster 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.
3. I understand that successful completion of a Taster Module does not guarantee acceptance onto the
Diploma/MSc programme at a later stage. Applications have to be made to the degree programme
following the standard UCL procedures for post-graduate programmes. Taster students can only gain
exemption from these modules on the full degree programme providing they have successfully
registered on the degree programme within 2 academic years after passing the Taster module.
4. If in future I do apply and am accepted onto the MSc or PGDip in Clinical Paediatric Neuropsychology
then I am aware that I will need to come in person in the September of that academic year to enrol
even if the next module I am doing does not start until December of that year.
5. To the best of my knowledge, the information on this application is accurate and complete. (Please
note that ICH reserves the right to refuse admission or to terminate a student’s attendance should it
be discovered that he/she has made a false statement or omitted significant information.)
6. 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
Please return this form to:
Programme Administrator
MSc Paediatric Neuropsychology
Institute of Child Health,
30 Guilford St,
London WC1N 1EH, UK