Centre for Professional Development & Lifelong Learning, School of Pharmacy Application Form To Study Individual Modules as Short Courses or Part of Another Programme Tel: 01782 734207 Return with the relevant course fee* and Equal Opportunities Monitoring form to: Mrs Bev Oakden, Postgraduate Programmes Co-ordinator, School of Pharmacy, Keele University, Staffs ST5 5BG or e-mail b.oakden@keele.ac.uk * NB: no course materials will be dispatched until the course fee has been paid. Clinical Pharmacy Programme CPD Plus+ and CPD Plus+ Open Learn Courses/Modules Please note that the availability of Open Learn courses/modules is subject to the programme manager’s approval at any time. Please contact the programme manager to check availability before you apply (d.knowles@keele.ac.uk; 01782 733561/734207). PART A Course Details Start Date: Module Code PHA-40049 PHA-40050 PHA-40051 PHA-40052 PHA-40053 PHA-40054 PHA-40055 PHA-40056 PHA-40057 PHA-40058 PHA-40125 PHA-40060 PHA-40061 PHA-40062 PHA-40063 PHA-40121 PHA-40065 PHA-40066 PHA-40067 PHA-40068 PHA-40073 PHA-40099 PHA-40116 Mode of Attendance CPD Plus + 10 credits Title Education Theory and Practice for Health Professionals (only for March/April start) Surgical Respiratory Disease Renal Disease Monitoring Therapy Medicines Management & Pharmaceutical Care Mental Health Malignant Disease Joint Disease Infections Neonatal and Child Health HIV & AIDS Cardiovascular Disease 1 Gastrointestinal Disease Endocrine Disease Quality in Healthcare & Evidence Based Practice (only for January start) Central Nervous System Diseases Critical Care & Parenteral Nutrition Cardiovascular Disease 2 Hepatic Disease Advanced Practice Development / PhwSI Researching and Evaluating Your Practice Building Working Relationships for the Advanced Practitioner MOD Open Learn 15 credits Open Learn 30 credits not available not available not available not available not available Please tick one or more you wish to apply for this year PART B Personal Details First Names Title: Contact Address: Postcode: Country: Telephone: Fax: Email: Nationality: Surname/Family Name: Gender: Country of Birth: Date of Birth: Telephone: Fax: Email: Country of Residence: not available not available not available PLEASE EXPAND THE BOXES BELOW AS NECESSARY TO PROVIDE THE DETAILS REQUESTED. Academic and professional qualifications. Please include academic institution, degree classification and year attended. NB You are required to send in a copy of your degree certificate with your application form. Details of professional registration body and personal registration number: Current Employment. Please include your job title/role, employer’s name, address and date employment started. NB Please send your employer's reference with your application form If this module is undertaken as part of another programme please state Institution Course and Course Number Start Date End Date Briefly state reason for choosing module/s Data Protection Act The information contained in this form will be used for the purpose of processing your application and, if your application is successful, will form the basis of your University record. University Charter, Statute, Ordinances and Regulations Registration at Keele University is conditional upon observation of the University’s Charter, Statute, Ordinances and Regulations in effect at any time. A copy of the current version may be obtained from the University Secretary’s office or is available on the web at www.keele.ac.uk/depts/vc/plansec/regs/reglist.htm Please ensure that your application is complete and post together with a copy of your degree certificate and a reference from your employer. I hereby apply for admission to study at Keele University for the course set out above, and confirm that the information provided is correct to the best of my knowledge. Signature: Date: Postgraduate Programme in Clinical Pharmacy Declaration of Support from the Student’s Workplace Note for the workplace The Clinical Pharmacy Programme has been developed specifically for hospital pharmacists. The course learning materials, activities and assessments are designed to relate to actual clinical practice to make the student’s learning experience more meaningful to their own environment. Students will require access to patients and wards to enable the student to meet the course learning outcomes and complete work based course work for the student’s Reflective Portfolio and other assessments. They will therefore need the support of their workplace to access this information. Students are advised that all information they use to help them complete their course work should remain confidential and that no patients, colleagues, or other individuals should be named. Respective students must arrange for this declaration form to be completed by an appropriate person in the workplace, and submit it with their course application. Please complete the details below in BLOCK print. Student’s Name ………………………………………………………………………………………… Name of Supporter …………………………………………………………………………………….. Supporter’s Organisation/Address …..………………………………………………………………. …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Telephone ………………………………………….. Email address ……………………………….. Supporter’s Position in the Organisation …………………………………………………………… I agree to provide the support required for the above named student to complete the course work for the Postgraduate Programme in Clinical Pharmacy. Signature ……………………………………………………………… Date ………………………… (Please ensure that this form is completed and returned with your application) KEELE UNIVERSITY EQUAL OPPORTUNITIES MONITORING Please help us to make our equal opportunities policy effective by ticking the boxes applicable to you. ETHNICITY 11 White-British 12 White-Irish 13 White-Scottish 14 Irish Traveller 19 Other White Background 21 Black or Black British-Caribbean 22 Black or Black British-African 29 Other Black background 31 Asian or Asian British-Indian 32 Asian or Asian British-Pakistani 33 Asian or Asian British-Bangladeshi 34 Chinese Ethnic background 39 Other Asian background 41 Mixed-White and Black Caribbean 42 Mixed-White and Black African 43 Mixed-White and Asian 49 Other Mixed background 80 Other Ethnic background 90 Not known 98 Information refused DISABILITIES The University welcomes applications from people with disabilities and considers them on the same academic grounds as those from other candidates. If you indicate on this form that you have a disability, and if we make you an offer of a place, we will then inform our Disability Services department who will contact you to discuss your support needs. 00 No known disability If you have a disability, please indicate those which are applicable to you. 01 Dyslexia 02 Blind/ partially sighted 03 Deaf/ hearing impaired 04 Wheelchair user/ mobility difficulties 05 Personal care support 06 Mental health difficulties 07 An unseen disability, eg. diabetes, epilepsy, asthma 10 Autistic Spectrum Disorder/ Asperger’s Syndrome 08 Multiple disabilities 09 A disability not listed above (please specify) Please return this form with your application form. Many thanks for your assistance. Payment Module Costs 2013 / 14: 10 credits - £405 / 15 credits - £610 / 30 credits - £1150 for UK and EU students Module costs from 1st August 2014: 10 credits - £440 / 15 credits - £660 / 30 credits - £1188 (for UK and EU students) Payment can be made by cheque or debit or credit card (not Amex) Cheque I enclose a cheque made payable to Keele University for £________________ Card Name on card: ___________________________ Card type: ___________________ Card number Expiry Date Valid From Security code Issue Number (last three digits on reverse) (where applicable) Amount to be charged £______________ Cardholder Address: _______________________________________________________ ______________________________________________________________________________ _______________________________________________ Postcode ______________ Cardholder Contact Number _________________________________________________ Student Name (if different from cardholder) _________________________________________________ Please return completed application form, equal opportunities form and payment to: Mrs Bev Oakden, Postgraduate Programmes Co-ordinator, School of Pharmacy, Keele University, Keele, Staffs ST5 5BG or e-mail b.oakden@keele.ac.uk