Registration Form

Internal Candidate
External Candidate

Title *

First Name *

Last Name *

Preferred Name *

Professional Registration No *

Telephone No *

Trainee Email (NHS address preferred) - Important, use of a managers or admin email will result in the booking being void *

Job Title *

Manager's Email *

Ward/Department *

Band/Grade *

Correspondence Address *

Additional Learning Needs

Course Applied For *

Please Read Carefully

Please contact us immediately of any changes to this information, especially your ward or department as your course information and manual will be sent to the Ward or Department quoted above.
Candidates must inform the Resuscitation Training Department urgently if they have to withdraw from the course. This may enable us to fill the space with candidates from the waiting list
Courses can only guaranteed for those whom require it for their statutory & mandatory training.
I confirm that my manager is aware and has approved this application.
Please check your email regularly for information about your course and course material

Digital Signature

By filling out your full name below, this acts as a digital signature and that you can confirm all of the information provided above is correct and valid.

Full Name *

Date *

You will receive an email receipt after submission.

Manager booking themselves - Confirmation *
In order to use the same email address in the Trainee and Manager's email boxes, you must tick this box to confirm you are happy with this. The Trainee email MUST be the actual Trainee's email address as it used to assign the booking account. If it is NOT used, the booking will not be completed.

Title *

First Name *

Last Name *

Preferred Name *

Job Title *

Email Address (NHS address preferred) *

Telephone No *

Address *

Postcode *

Prof. Reg Num *

RCS number for ATLS & CCrISP only

Band/Grade *

Speciality *

Employer *