Faculty of Nursing & Midwifery
Application Form 2013-2014
Section 1: Your Details
Surname/Family Name:
Home Address Line 1:
First Name:
Home Address Line 2:
Date of Birth:
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/
Home Address Line 3:
Male/Female:
Home Address Line 4:
Mr/Mrs/Ms/Miss/Other:
Home Telephone: (include area code):
PPS Number :
Mobile Number:
Nationality:
Email Address:
Country of Birth:
An Bord Altranais pin number:
If you are resident in Ireland, please state date of first entry into
Ireland:
/
/
Have you previously been a student with the Faculty of Nursing and
Midwifery at the Royal College of Surgeons in Ireland? Yes
No
If Yes, Student Number:
Section 2: Programme Choice
Please tick one
PhD
Fellowship Faculty of Nursing & Midwifery (FFNMRCSI)
Master Degree Programmes (MSc):
- MSc (Research)
- MSc in Nursing – Taught
- MSc in Nursing- Year 2—Available Postgrad Diplomas Students
- MSc in Nursing (Advanced Leadership)
- MSc in Nursing (Advanced Nurse Practice)
- MSc in Nursing (Advanced Nurse Practice in
)
Certificate, Diploma & Degree Programmes
- BSc in Nursing
- BSc in Nursing Management
- Pathway to Postgraduate Diploma (For Non Graduate Students)
- Care of the Older Person in a Residential/Nursing Home Setting
- Certificate in Nursing - Clinical Research(Level 9)
Post Graduate Diploma Programmes:
In Association with Beaumont Hospital
- Postgraduate Diploma in Emergency Nursing
- Postgraduate Diploma in Coronary Care Nursing
- Postgraduate Diploma in Intensive Care Nursing
- Postgraduate Diploma in Neuroscience Nursing
- Postgraduate Diploma in Operating Department Nursing
- Postgraduate Diploma in Renal Nursing
- Postgraduate Diploma in Oncology Nursing
- Postgraduate Diploma in Gerontological Nursing
In Association with Cappagh National Orthopaedic Hospital
- Postgraduate Diploma in Orthopaedic Nursing
In Association with Connolly Hospital Blanchardstown
- Postgraduate Diploma in Gerontological Nursing
In Association with The National Maternity Hospital, the
Rotunda Hospital, the Coombe Women and Infants University
Hospital, Our Lady of Lourdes Hospital, Drogheda
- Postgraduate Diploma in Neonatal Intensive Care Nursing
Post Graduate Diploma Programmes:
In Association with Royal Victoria Eye and Ear Hospital
- Postgraduate Diploma in Practice Nursing
- Postgraduate Diploma in Ophthalmic Nursing
- Postgraduate Diploma in Infection Control Nursing
- Postgraduate Diploma in Ear, Nose & Throat Nursing
- Postgraduate Diploma in Wound Management & Tissue Viability
- Postgraduate Diploma in Respiratory Care in Nursing Practice
In Association with Our Lady’s Children’s Hospital, Crumlin
- Postgraduate Diploma in Pain Management
- Post Graduate Diploma in Nursing (Peri-operative Children’s
Nursing)
Section 3: Education and Professional Experience
Education
Institution
Details
Qualification
Year of Award
Institution
Details
Qualification
Year of Award
Institution
Details
Qualification
Year of Award
Professional Experience
Current Post
Present Employer
Current Role & Grade
Date/Year of Commencement
Ward
Ward Speciality
Previous Post
Present Employer
Current Role & Grade
Date/Year of Commencement
Ward
Ward Speciality
Previous Post
Present Employer
Current Role & Grade
Date/Year of Commencement
Ward
Ward Speciality
Section 4: EU Status
To be eligible for EU Fees – Candidates must have one of the following: (please tick as appropriate)
EU Passport
Original EU National Identity Card
Original Irish Birth Certificate
Working in Ireland for a minimum of 2 years
Official Irish Refugee Status (requires the appropriate letter from the Department of Justice & Law Reform)
Section 5: Fees
Please tick as appropriate
I am paying my own fee:
A sponsor will be paying my fee:
if yes, please give details:
Section 6: Applicant’s Declaration
I certify that all information given is correct
I confirm that, to the best of my knowledge, the information given on this form is correct. I understand the making of false
statements may lead to withdrawal of an offer of a place. Yes
Date:
/
/
IMPORTANT – Please check & take note of the following:
1) A €50 application fee payable to the Faculty of Nursing and Midwifery, RCSI. Please send a cheque, postal order or bank
draft. APPLICATION FEE IS NON-REFUNDABLE
2) If you are sponsored by your Employer, please submit a letter from your Employer confirming this
3) If you are paying your own fees*, an initial payment of 25% of the required fee must be received no later than the day of
Registration. (*These facilities do not apply to students doing Stand Alone Modules)
4) If exemptions are requested, transcripts and other supporting documents must accompany this application with a €50 fee
5) Photocopied transcripts of previous academic awards should be sent to nursing@rcsi.ie or to the postal address below
6) Please note that the name you give on this Application Form is the name that will appear on your student ID card, college
records and parchment
Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St Stephen’s Green, Dublin 2
+353 (01) 402 2206/2445 | nursing@rcsi.ie | www.rcsi.ie/nursing