Application Form for PgDip/MSc in Physician Associate Studies Course 2016 Entry
Please return your application form and supporting documentation to:
Postgraduate Admissions Officer, Admissions, Registry, St George’s University of
London, Cranmer Terrace, London SW17 ORE
Telephone: 020 8725 0350
Fax: 020 8725 0841
Email: pgadmiss@sgul.ac.uk
Please ensure that the application form is word processed.
1.
Mode of Study
Please select your preferred mode of study:
Full-time
Part-time
If insufficient students register for a part-time stream, could you attend full-time?
YES
2.
NO
Personal Details
Title ..………….Surname………………………………………Forename……………………………....
Date of birth…………………..
Age on 1st Sep 2016………………….Gender……………………..
Home Address (in full)
…………………………………………………………………………………………………….................
…………………………………………………………………………………………………….................
……………………………………………………….Postcode…………………………………………….
Contact Address (if different)
…………………………………………………………………………………………………….................
………………………………………………………………………………………………………………..
……………………………………………………….Postcode…………………………………………….
Tel No. Home………………………………………Work…………………………………......................
Mobile ………………………………………………Email address…………………….........................
Nationality.………………………………………….Country of Birth……………………………………
Date of first entry into the UK……………………………………………………………………………...
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3.
Academic Qualifications
Please provide details of your university/ college education (i.e. first degree or level 6 or level 7
standalone modules you may have completed). Please ensure that these qualifications are listed
in chronological order, beginning with the most recent (classes and divisions and dates awarded
must also be identified). You are also required to declare any qualifications which are currently
under completion or pending result.
Qualifications (e.g. BA, BSc or Level)
Title of programme/field of study/ module:
Name of institution:
Country:
Summary of marks/results/class of degree:
Date start/end:
Qualifications (e.g. BA, BSc or Level)
Title of programme/field of study/ module:
Name of institution:
Country:
Summary of marks/results/class of degree:
Date start/end:
Qualifications (e.g. BA, BSc or Level)
Title of programme/field of study/ module:
Name of institution:
Country:
Summary of marks/results/class of degree:
Date start/end:
4.
Professional/Other Qualifications
Title of qualification
Name of awarding/ regulatory body
Date from/ to
4a. Professional Registration
Professional regulatory
body
Registered no.
Date registered
Expiry
date
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5.
English Language Proficiency
Please note that if English is not your first language, you must provide documentation of testing
and scores to accompany your application.
Is your first language English? Yes
No
Did you study at school/ university where you were taught in English? Yes
No
If yes, for how many years? ………………………………………………
If English is not your first language have you taken an English language examination?
Yes
No
If yes please give details of testing system: [name and address]
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Date ……………………………… Overall Score ……………………………………………………...
6.
Current Experience and Employment
Current post…………………………………………………………………………………………...........
Employer…………………………………………………………………………………………………….
Work address………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
Email address…………………………………………………. Tel no …………………………………..
Summary of responsibilities
………………………………………………………………………………………………………………
…………….…………………………………………………………………………………………………
………………………….……………………………………………………………………………………
……………………………………….………………………………………………………………………
…………………………………………………….…………………………………………………………
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6a.
Previous Employment History
Please provide details of each post, employers and dates in chronological order
Post
6b.
Employer
From
To
Work and Voluntary Experience
Please list in the table below, any recent voluntary or work experience which you have
undertaken. Please ONLY include placements which have been undertaken in healthcare or
allied healthcare professions/environments within the last 3 years.
Name of
organisation
7.
Duration of
placement, (start and
end dates)
Hours
worked
per week
Short description of duties
Statement by Applicant
Please attach a written statement of no more than 500 words per question addressing both of
the following:
1) Describe how you think the role of a physician associate fits into the UK health care
system.
2) Discuss your motivation to become a physician associate, highlighting details of the
experience, qualifications and personal qualities you will bring to the course.
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8.
Referees
Please provide the particulars of two referees (one of whom should be academic) who are
prepared to support your application. On submission of your application, please ensure that you
send each of the below referees the Reference Request form to complete. This form can be
downloaded from the SGUL website. References from family or friends are not accepted.
Name…………………………………………………………………………………………………………
Address………………………………………………………………………………………………………
………….……………………………………………………………………………………………………
Telephone………………...…………………… Position held/ nature of relationship…………………
Name…………………………………………………………………………………………………………
Address………………………………………………………………………………………………………
………….…………………………………………………………………………………………………….
Telephone…………………………………….. Position held/ nature of relationship………………….
9.
Funding
Please indicate who will fund your studies:
Self
Family
Employer
Other
If other, please give details of sponsorship/ scholarship obtained:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
10.
How did you hear about the course?
Received an email from UCAS about Physician Associate Courses
Other (please give details below)
…………………………………………………………………………………………………………….…
………………………………………………………………………………………………………….……
11.
Dual registration and Declaration
PLEASE CONFIRM BY TICKING THIS BOX
that you are not currently on a programme of study at St George’s, University of London or any
other higher education institution, whereby you do not expect to receive award on or before 1
August 2016. Dual registration (concurrent registration on a programme of study) is not
permitted at St George’s and will prevent formal registration onto your chosen qualification of
study.
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Previous PA Study
Have you ever enrolled or registered on a Physician Associate Studies programme within the
UK, or elsewhere? Please tick one of the boxes below:
Yes
No
If you answered ‘yes’ to the above and did not complete this programme of study, please
disclose the reason/s below:
……………………………………………………………………………………………………………......
……………………………………………………………………………………………………………......
……………………………………………………………………………………………………………......
……………………………………………………………………………………………………………......
Please continue onto a sheet of A4 and attach to your application
Applicant’s signature………………………………………………… Date……………………….…….
12.
Equal Opportunities Monitoring Form
The completion of this form is voluntary, but the information it contains helps us to monitor and
improve our equal opportunities policies and procedures.
Ethnic Origin
Disability (please tick any that apply)
White - British
No disability
White - Irish
Specific learning difficulty (for example, dyslexia)
Other White Background
Blind or partially sighted
Black or Black British - Caribbean
Deaf or hearing impairment
Black or Black British - African
Wheelchair user or mobility difficulty
Other Black Background
Personal care support
Asian or Asian British - Indian
Autistic Spectrum Disorder or Asperger Syndrome
Asian or Asian British - Pakistani
Mental health difficulty
Asian or Asian British - Bangladeshi
Unseen disability e.g. diabetes, epilepsy
Chinese
Other, please specify below
Other Asian Background
……………………………………………………………………
Mixed-White and Black Caribbean
Mixed-White and Black African
Mixed-White and Asian
Other Mixed Background
Other Ethnic Background
Not Known
Prefer not to say
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