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LaSE Educational Supervisors Application Form
Please complete all required sections. All submissions will be reviewed to ensure entry criteria have been fulfilled and successful applicants will be contacted directly by the training provider.

For Information:
The Introductory webinar has been scheduled for 8pm on 22nd March 2018 or 1pm on 23rd March 2018. If you are unable to attend one of these webinars, please contact Nichola Baker via email: Nichola.Baker@hee.nhs.uk

This course is NHS funded, delivered by the Pharmacy Training Company. Enrolled participants who do not complete the course within the given deadline/s will incur a penalty charge from NHS Health Education England to cover the cost of the course.

For more information, please visit our website for Terms & Conditions and Frequently Asked Questions.

Before completing this application form, we would encourage you to discuss with your line manager (if applicable) to ensure this course meets your learning needs.
Personal Details
Surname *
Your answer
First Name *
Your answer
Email Address *
Your answer
Telephone number *
Your answer
Your Profession *
How Many Years Have You Been A Tutor/Educational Supervisor? *
Your answer
Are You A Named Tutor/Educational Supervisor For: *
About Your Workplace
In Which Sector Do You Supervise Trainees? *
Name of Pharmacy *
Your answer
First Line of Pharmacy Address *
Your answer
Town *
Your answer
Region *
Postcode *
Your answer
Is Your Training Site Registered With ORIEL For 2018-2019 Recruitment?
Only answer this question if you are a pre-registration pharmacist educational supervisor
A virtual peer network of Educational Supervisors will be created in each training locality. Please indicate if you are willing for your phone number to be shared with your peers in creation of this network *
Housekeeping
By enrolling on this training you are entering into a commitment with Health Education England London and South East and the Pharmacy Training Company (the training provider). We undertake to provide you with full support to enable you to complete the training programme. Please indicate your acceptance of our terms of enrolment by completing the sections below
You commit to completing the training programme within the specified time *
Required
You commit to completing any evaluation forms required by HEE or the training provider regarding your training *
Required
You understand that HEE will levy a training fee if you fail to complete the programme as requested *
Required
Please provide a full postal address, including postcode, where invoices should be sent in the unlikely event that you are unable to complete your training.
This address should not be your employers address.
First line of address *
Your answer
Second line of address
Your answer
Region *
Your answer
Postcode *
Your answer
You understand that there is no appeals process in the unlikely event that you are removed from the course.
Terms and Conditions
Before you submit your application please ensure you have read the terms and conditions carefully.
By ticking this box and submitting your application form, you confirm that you have read and agree to all the terms and conditions.
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