University of Malta
Faculty of Health Sciences
Application for Registration for Continuing Professional Development Study-Units
Academic Year 2016-17
Application No.
Section A: APPLICATION FOR STUDY-UNITS OFFERED DURING ACADEMIC YEAR 2016-17
st
nd
Tick one box from 1 preference and one box from 2 preference
st
nd
1 pref.
2 pref.
Code
Study-Unit Title
Semester
HSC4061
Clinical Education in Practice (Mentorship)
Semester 1
MNH4001
Child and Adolescent Mental Health
Semester 2
NUR3234
Infection Prevention and Control
Semester 1
NUR3283
Dimension of Quality Management in Health-Care Service
Provision
Semester 1
NUR4240
The Spiritual Dimension in Holistic Care
Semester 2
NUR4241
Transitional Care: The Discharge Process and Continuity of
Care
Semester 1
NUR4408
Community Child Care
Semester 1
NUR4409
Community Child Care Related to Practice
Semester 1
NUR4410
Community Care of the Elderly
Semester 1
NUR4411
Community Care of the Elderly Related to Practice
Semester 1
NUR4414
Community Care of the Adult
Semester 2
NUR4415
Community Care of the Adult Related to Practice
Semester 2
POD5001
Vascular Assessment of the Lower Extremities
Year
RAD3010
Principles and Practice of Imaging: Administration of
Prescribed Medicinals by Radiographers
Semester 1
Section B: PERSONAL DETAILS (USE BLOCK LETTERS)
I.D. Card No. _______________________
Gender: Male
Female
Surname*: ________________________
Name*: ______________________________
Maiden Surname: ___________________
Date of Birth: ___/___/___
Age: ________
dd mm yyyy
Post: ______________________________
Affix original
recent
passport
photograph
here
Present Place of Work: __________________
Ward/Area: ___________________________
Nationality: (1) ___________________________
(2) _____________________________
Address:
House No.: ___________________________
Home Tel. No.:
___________________________
Street:
___________________________
Work Tel. No.:
___________________________
Town:
___________________________
Mobile No.:
___________________________
Postcode:
___________________________
Email Address:
___________________________
Country:
___________________________
*
This is the name that will appear on your transcript of results.
POSTAL ADDRESS: MSIDA MSD2080, MALTA
TEL: (+356) 21333903-6 WEBSITE: http://www.um.edu.mt DDI: (+356) 2340 + Ext. No. E-MAIL: healthsciences@um.edu.mt
Section C: PROMOTIONAL MATERIAL AND QUESTIONNAIRES
The Registrar receives requests to forward emails on behalf of University of Malta / Junior College staff /
students, Senate recognised students' organisations related to activities being organised, questionnaires
required for research etc.
Would you agree to receive such material?
Yes, I agree
No, I do not agree
Section D: NEXT OF KIN
Relationship to Applicant: ________________ Surname: _________________
Address: Same as Applicant?
If No, please specify:
Yes
Name: _______________
No
_____________________________________________________________________
____________________________________________ Postcode: ______________
Telephone/Mobile No.: ____________________
Section E: DISABLED APPLICANTS/MEDICAL CONDITION
Do you have any disability that the University of Malta should be aware of? Tick
Yes
as appropriate
No
If yes, please specify:
Hearing Impairment
Mobility Impairment
Specific Learning Difficulty
Visual Impairment
Other ___________________________________________________________
Please let us know if you have any particular requirements due to a disability or long term condition. This
information will be used to enable us to provide you with appropriate help and services to facilitate your
studies at the University.
Section F: ADDITIONAL INFORMATION
Only one application should be submitted.
Applicants are to submit the certificate of registration/enrolment for verification purposes.
The Departmental Manager’s approval is compulsory for acceptance on these units.
Application forms must be handed in personally to Ms Kelly Grech, Room 30, Faculty of Health
th
Sciences, Block A, Level 1, Mater Dei Hospital by the deadline of 24 June 2016.
Section G: STATEMENT OF INTEGRITY
It is important to read carefully the statement below before ticking the box.
I declare that the information given is correct and complete. I am aware that the application will not be
considered if incorrect or incomplete information is given. I hereby authorise the University of Malta to
request and obtain any information from any institution, entity, body, unit, organ and/or organisation,
provided this information is considered necessary by the University of Malta for the purposes of this
application. The University of Malta reserves the right to withdraw or amend any offer made or terminate
any subsequent registration should the information given in the application be found to be incorrect.
I am aware that my personal data may be used as follows: for internal business processes of the University,
research purposes, as required by the Laws of Malta or in cases where in the opinion of the Registrar it is in
my interest to do so. Computer and paper records are kept about each student’s studies, both during the
course and after completion of studies.
____________________________
Applicant’s Signature
____________________________________
____________________________
____________________________
Approval by Departmental Manager
(Name in full)
Signature
Date