King s Health Partners (KHP) Orthodontic Therapy Training Programme

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1 King s Health Partners (KHP) Orthodontic Therapy Training Programme Candidate Application Form Terms & Conditions 2016/ P a g e

2 King s Health Partners (KHP) Orthodontic Therapist Training Programme Student Orthodontic Therapist Application Form 2016 (Please complete this form electronically, or legibly, using black ink only) A. PERSONAL DETAILS TITLE: FORENAME: SURNAME: GDC Number: ADDRESS OF PROPOSED TRAINING SITE (Practice address) : NAME OF TRAINER: TRAINER GDC No: Please confirm if you have been working at the above proposed training site for more than 3 months? Yes No Please confirm if your trainer is already registered on to the Supervising Orthodontist GDC register? Yes No HOME ADDRESS: Please specify preferred address for communication i.e. Practice or Home: 2 P a g e

3 PERSONAL CONTACT DETAILS Personal Personal mobile: Personal home line: QUALIFICATIONS (INCLUDING DATES): QUALIFICATION: AWARDING BODY: DATE: 3 P a g e

4 B. EMPLOYMENT DETAILS: Please give a full employment history (with dates) since leaving school Name and Address of Employer(s) No of sessions Dates of Employment P a g e

5 Please continue on separate sheet if necessary 5 P a g e

6 PLEASE GIVE DETAILS OF ORTHODONTIC EXPERIENCE: Including dates and the number of sessions per week (300 words or less) LIST RELEVANT TRAINING COURSES ATTENDED WITHIN LAST 5 YEARS: Please continue on separate sheet if necessary 6 P a g e

7 C. ADDITIONAL INFORMATION REQUIRED FROM APPLICANT: Have you applied for any other Orthodontic Therapist Training Programmes? Yes No If yes, please state where: Have you applied for any other course starting in 2016? Yes No If yes, please state the name of the course that you have applied for: Are you currently enrolled or have you recently started any other course(s)? Yes No If yes, please state the name of the course that you have enrolled onto or are due to start and finish: Will the course be funded by you or your proposed training site? Applicant (You) Training Site Have you gained prior approval from the Supervising Orthodontist to support this application? Yes No 7 P a g e

8 D. REASON FOR APPLICATION Describe why you wish to undertake training to become an Orthodontic Therapist at King s (300 words or less) 8 P a g e

9 E. STATEMENT IN SUPPORT OF YOUR APPLICATION Taking into account the person specification for Students, please provide any other information that may be relevant to your application. This could include examples of working in a team, illustrations of your communication and interpersonal skills, examples of organisation and setting priorities drawn from work or from other outside activities. (300 words or less) 9 P a g e

10 F. REFEREES Please provide the names and addresses of two professional referees, one of which must be your current employer, who will support your application 1. TITLE: NAME: OCCUPATION: ADDRESS: ADDRESS: How many years has this person known you? In what capacity? 2. TITLE: NAME: OCCUPATION: ADDRESS: TELEPHONE NUMBER: ADDRESS: How many years has this person known you? In what capacity? TELEPHONE NUMBER: Falsifying information on this application will be deemed as acting in an unprofessional manner. This will have implications on registration with the regulatory body. (Standards for Dental Professionals 2006 GDC) Please enclose 2 coloured passport-size photographs with your application. Photographs must be submitted with your application and will not be accepted after the deadline date. Signed (Applicant): Date: 10 P a g e

11 Please indicate how you heard of this course: Additional Information Required Advertisement Recommendation Friend Employer Other (please specify) Tick Internet Poster Prospectus Careers Office GDC Tick KHP welcomes applications from people with special needs and considers them on the same academic grounds as those from other candidates. It is helpful to know about your special needs in advance so that we can discuss whether facilities are available. If you have special needs please tick the appropriate box. Dyslexia Please specify Need Personal Care Support Please specify Blind/partially sighted Mental Health Difficulties Deaf/hearing impaired Other special needs please specify: Wheelchair user/mobility difficulties An unseen special need e.g. Diabetes, epilepsy, asthma Are you a registered disabled person? Do you have any criminal convictions or cautions? If you have answered yes to any of the above please give details: Yes No 11 P a g e

12 Equal Opportunities Monitoring (UK students only): Please help us to make our equal opportunities policy effective by placing a tick in the appropriate box which is applicable to you Asian or Asian British Indian Pakistani Bangladeshi Chinese Other Asian background Black or Black British Caribbean African Other black background Mixed Race White and black Caribbean White and Asian Other mixed background White and black African White British Irish Other white background Other Other Ethnic Background Please state: 12 P a g e

13 Terms & Conditions The information you provide will be held by King s Health Partners. The information will not be shared with any other body without your express consent. It will be used solely in connection with the operation of the Diploma in Orthodontic Therapy and stored in accordance with the Data Protection Act We will only use the information you have supplied for administrative purposes. The course may occasionally be requested to supply data to members of staff for research purposes, such as mailing of questionnaires. Please tick box if you DO NOT wish your personal data to be used in this way While we make every effort to run courses as advertised, we reserve the right to change the timetable where necessary and /or the teaching staff without prior notice and to cancel any courses without liability. As the candidate you will comply with the standards and regulations set out by the course leads. Failure to do so may result in course dismissal. Term 1 I understand that the course fee is a non- refundable fee and that the work place practice is liable for the full course fee of 13,000 regardless of whether or not I the trainee complete the course to its entirety. Term 2 I understand that the course fee is a non- refundable fee and that I will be liable for the full course fee of 13,000 regardless of whether or not I complete the course to its entirety. Yes Yes No No I confirm that I have read, understood and agree to comply with the terms and conditions of the Orthodontic Therapy Course above. Signed (Applicant ): Date: 13 P a g e

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