Guidance notes for completing the continuing studies application form.
1.
Please complete all personal details, ensuring that you enter your date of birth – this is required in order for us to
cross check all of your personal details held on the University database. Please include your CCCU e-mail address
as this will be our route of communication with you (SECTION A).
4.
Please indicate the source of funding. If you are self-funding, you will be invoiced separately by the University on
commencement of your module (SECTION D, PART TWO).
5.
If you are being sponsored, you must indicate the name of your Trust/Sponsor. You will need to obtain the correct
signature of your authorised fund-holder on the form. Please note that this is in addition to the signature of your
ward/line manager – these are not the same person (SECTION D, PART ONE).
8.
Please complete SECTION F if you are applying for Degree (Level 6) or Masters (Level 7) study.
Once completed correctly and signed by the relevant parties, all forms should be returned to the relevant address as
indicated below. Please note: Any incomplete applications will be returned to you and there will be a delay in
processing your application.
ALL OTHER PROGRAMMES:
Post Registration and Foundation Degree Health Team
Faculty of Health & Social Care
Canterbury Christ Church University
Canterbury
Kent CT1 1QU
E-MAIL: postregandfd-healthadmin@canterbury.ac.uk
MSc CARDIOLOGY/MCH MINIMALLY INVASIVE
SURGERY PROGRAMMES ONLY:
Allison Allen
Faculty of Health & Social Care
Medway Campus
30 Pembroke Court
Chatham Martime
Kent ME4 4UF
E-MAIL: medway-healthadmin@canterbury.ac.uk
SECTION A – TO BE COMPLETED BY ALL STUDENTS
MR/MRS/MISS/MS (please circle or add another title)
FORENAME:
SURNAME:
PREVIOUS SURNAME (IF APPLICABLE):
Address (Home):
Address (Work):
Tel No:
Tel No:
Mobile:
Directorate/Division (if applicable):
Date of Birth: dd/mm/yyyy
Profession (e.g. OT):
CCCU E-mail address (This will be our main method of contacting you to confirm receipt of your form. Please check your
Spam / Junk folder if you have not received confirmation in your inbox.):
Date of Commencement of Programme of Study (Month and Year):
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Continuing Students Application Form April 2015
SECTION B – TO BE COMPLETED BY ALL STUDENTS
DISABILITY
Do you have a disability which we ought to consider? If yes please complete the table below.
DISABILITY (TYPE)
No known disability
Wheelchair user/mobility
difficulties
Dyslexia
Personal care support
Blind/partially sighted
Mental health difficulties
Deaf/hearing impairment
Multiple disabilities
A disability not listed
Autistic Spectrum
Disorder
An unseen disability: e.g.
diabetes, asthma, epilepsy
SECTION C – TO BE COMPLETED BY ALL STUDENTS
FEE STATUS
We need information from you to determine your fee status. If this section of the form is not complete the University will presume
that for fee purposes, you are an overseas fee payer.
Are you a UK National?
Yes / No
Are you an:
EEA National
Swiss National
Turkish worker in the UK
In which countries have you been resident for the last three years?
Country
Main purpose of your residence
1
1
2
2
3
3
4
4
Applicants not born in the European Union, please state:
Date of first entry to the EU:
dd/mm/yyyy
Date of most recent entry to the EU
dd/mm/yyyy
If you are not a UK National or EEA/Swiss National please state:
Country of birth:
Nationality:
Country of residence:
Address:
Do you require a student visa?
Do you require a student visitor visa (for
students studying six months or less)
YES / NO / DON’T KNOW
YES /NO / DON’T KNOW
If you are not a UK/EEA citizen and do not require a student visa, what is your UK immigration status?
Indefinite Leave to enter/remain
YES / NO
Discretionary Leave to remain
YES / NO
Refugee status granted
YES / NO
Spouse of student visa holder
YES / NO
Dependent of student visa holder
YES / NO
Work Permit
YES / NO
Other (please state):
Start and end dates of current leave (UK Immigration Permission) if applicable
Start Date
dd/mm/yyyy
SECTION D – TO BE COMPLETED BY ALL STUDENTS
End Date
dd/mm/yyyy
FUNDING
PLEASE CONFIRM HOW YOUR STUDIES WILL BE FUNDED
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Continuing Students Application Form April 2015
SOURCE OF FUNDING (please
tick)
SPONSORED
SHARED
SELF
ONCE YOU HAVE COMPLETED THIS FORM, PLEASE RETAIN A COPY & WHERE APPLICABLE RETURN IT
TO YOUR AUTHORISED FUND HOLDER FOR APPROVAL & FORWARDING TO CANTERBURY CHRIST
CHURCH UNIVERSITY.
STUDENTS WHO ARE BEING FUNDED BY THEIR EMPLOYER SHOULD COMPLETE PART ONE,
STUDENTS WHO ARE SELF-FUNDING SHOULD COMPLETE PART TWO.
PART ONE - FOR SPONSORED/SHARED SPONSOR STUDENTS ONLY
Authorised signatories:
Darent Valley Hospital
East Kent Hospitals NHS Trust
East Sussex Healthcare NHS Trust
Kent Community Health NHS Trust
Kent and Medway NHS and Social Care
Maidstone and Tunbridge Wells NHS Trust
NHS Kent and Medway
Medway Community Healthcare
Medway Maritime Hospital
Pilgrims Hospice
Southeast Coast Ambulance Service NHS Foundation Trust
Name of Trust/Sponsor (BLOCK CAPITALS) if not listed above:
Sue Prime
Ann Broadhead / Lesley Bourne
Barbara Gosden / Angela Jarvis
Helen Hatter
Lorna Hunt / Sue Rose / Emma Matthews
Marian Palmer
Joanne Purkiss / Andrea Vigille
Frances Regan / Sam Robinson
Tracy Perkins / Ursula Clarke
Paula Evans / Suzz Keith
Pam Fricker / Craig Mortimer
By signing below, I agree to pay the fees for the applicant to attend the programme/module, as detailed overleaf and I
agree to provide a mentor (if required).
Name of Employer/Trust:
Trust/Company Stamp
Contact telephone no:
Signature of Authorised Signatory:
Name of Authorised Signatory (BLOCK CAPITALS):
Line Manager Agreement
I support this application and agree that a mentor will be provided (if required):
Manager’s signature:
YES / NO
Date:
If you are being sponsored by your employer, by signing this form you are consenting to the University sharing information
with your employer about your attendance at Registration and on modules and results
Signature of student:
Date:
PART TWO - FOR SELF-FUNDING STUDENTS ONLY
An invoice will be sent to you at the address given on page one of this application form.
By signing this form, you are agreeing to pay the tuition fees as invoiced. Details of the modules fees can be obtained from your
Programme Administrator.
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Continuing Students Application Form April 2015
Signature:
Date:
SECTION E – TO BE COMPLETED BY THOSE STUDENTS WHO KNOW THAT THE MODULES THEY WILL BE
UNDERTAKING REQUIRE ASSESSMENT IN PRACTICE
NOMINATED MENTOR OR PRACTICE ASSESSOR
MR /MRS /MISS /MS (please circle or add another
title)
SURNAME:
FORENAME:
Address (Work)
Details of Mentorship Qualifications (if applicable)
Tel No:
E-mail address:
SECTION F – TO ONLY BE COMPLETED BY STUDENTS APPLYING FOR DEGREE (LEVEL 6) OR MASTERS
(LEVEL 7) STUDY. STUDENTS APPLYING FOR THE FOUNDATION DEGREE DO NOT NEED TO COMPLETE THIS
SECTION
MODULES
If known, please identify which modules you wish to apply for in the boxes below. Please indicate at which Level you wish to
study. YOU CANNOT MOVE BETWEEN LEVELS OF STUDY, AFTER THE START OF THE MODULE. Please contact
your Personal Academic Tutor/ Programme Director if you require additional pathway planning advice.
Academic Year:
Semester 1 (September – January)
Circle as appropriate
First Module
Location (where module is delivered in more
than one location)
Non-accredited
BSc
MSc
Second Module (only complete if you wish to
study two modules in semester one)
Location (where module is delivered in more
than one location)
Semester 2 (February – June)
Non-accredited
BSc
MSc
Circle as appropriate
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Continuing Students Application Form April 2015
First Module
Location (where module is delivered in more
than one location)
Second Module (only complete if you wish to
study two modules in semester one)
Location (where module is delivered in more
than one location)
Non-accredited
BSc
MSc
Non-accredited
BSc
MSc
PLEASE SEE TIMETABLE FOR CUT OFF DATES FOR APPLICATIONS.
APPLICATIONS RECEIVED AFTER THE CUT OFF DATE WILL NOT BE ACCEPTED
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Continuing Students Application Form April 2015