British Paediatric Neurology Association distance learning



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British Paediatric Neurology Association

DISTANCE LEARNING

Application Form to begin course January 2010

Instructions (any difficulty please email info@bpna.org.uk or telephone 01204 492888):



  1. a) On your browser click ‘File’ and then ‘Save As’. Save this form to your computer.

  1. Save the file again as ‘File Name: your surname and initials’ and ‘File Type: Word Document

  1. a) Complete the personal details section.

  1. Complete ‘Why you would like to do the BPNA distance learning course’ (100 word limit).

  2. Paste a copy of your cv on to the end of the form.

  3. Save the document.

3. Email the completed document as an attachment to: info@bpna.org.uk

4. Closing date for applications is 31 October 2009.




Personal Details:


Title: First Name: Surname:

Hospital employed at:

Deanery:

Address for correspondence:

Postcode:

Work Telephone: Home Telephone:

Mobile:

Email:

Grade: Trainee / Career Grade

If Trainee, CCST Date: _______________ Are you in a National Grid Post? Yes / No



Why would you like to do the BPNA distance learning course?

Please write why you would like to do this course in no more than 100 words:
I would like to do the British Paediatric Neurology Association’s distance learning course because

Educational Supervisor:

I have read ‘Information for Educational Supervisors’ (www.bpna.org.uk/DL/infoedsup.pdf) and have agreed to be the applicant’s educational supervisor if they are offered a place on the distance learning course.
Title: First Name: Surname:

Position:

Address for correspondence:

Postcode:

Work Telephone:

Email:


Have you attended a distance learning Educational Supervisors’ training?
Curriculum Vitae

Applicant, please paste a copy of your CV here.


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