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
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:
Address for correspondence:
Have you attended a distance learning Educational Supervisors’ training?