Administration Use Only Learner Reg. No. Course Code Complete and return this form to: Education Department, St Christopher’s Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ. Forms can be faxed to: 020 8776 5838 or emailed to education@stchristophers.org.uk Personal Details First Name(s) Surname Date of Birth Gender Organisation Address Post Code Profession Home Address Post Code Email Address Home Telephone Mobile Number Dietary Requirements Next of Kin Emergency Contact Details Name Relationship to you Phone Number Mobile Qualification being applied for Course Code Course Title Start Date End Date Fee 19th Mar 20th Mar £1,200 QELCA© Train the Trainer QELT18 2018 2018 Please attach your current curriculum vitae (CV) to this application ensuring that your palliative care experience and qualifications are CV attached included. Fees Please raise an invoice for the fees as follows: Invoice To: Total Invoice Value: Purchase Order No. (name and address of Fee Payer) (if applicable)
Administration Use Only Learner Reg. No. Course Code Complete and return this form to: Education Department, St Christopher’s Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ. Forms can be faxed to: 020 8776 5838 or emailed to education@stchristophers.org.uk Personal Details First Name(s) Surname Date of Birth Gender Organisation Address Post Code Profession Home Address Post Code Email Address Home Telephone Mobile Number Dietary Requirements Next of Kin Emergency Contact Details Name Relationship to you Phone Number Mobile Qualification being applied for Course Code Course Title Start Date End Date Fee QELT18 QELCA© Train the Trainer 19th Mar 2018 20th Mar 2018 £1,200 Please attach your current curriculum vitae (CV) to this application ensuring that your palliative care experience and qualifications are included. CV attached Fees Please raise an invoice for the fees as follows: Invoice To: (name and address of Fee Payer) Total Invoice Value: Purchase Order No. (if applicable)
QELCA-TtT-March-2018-Application-Form.docx