Instruct on National Resuscitation Courses

Course applying for*

Name*

Prefix First Last

Name for your name badge

Preferred pronoun

Role Type*

Doctor
Doctor in training post at St George's Hospital
Nurse
Midwife
Physicians Associate
Other AHCP

If applying for GIC: Select the provider course type(s) you were nominated as an IP from:*

ALS
EPALS
APLS
NLS
Other

Date & Location of Provider Course*

If applying for ILSi: Select the provider course type(s) you were nominated as an IP from:*

ALS
EPALS
ILS
PILS

Date & Location of Provider Course*

Job Title & Department*

e.g. ST3, Anaesthetics; or Band 5 Nurse, Intensive Care

GMC/NMC/HPC Registration Number

Place of Work

St George's Hospital

Email*

Address*

Street Address Address Line 2 City Post Code

Phone

Have you previously registered with the Resuscitation Council, UK LMS?

Yes
No

Do you require any reasonable adjustments to be made for an additional need?

Do you have an specific dietary requirements or allergies?

For the purposes of this course only, I consent to St George's Hospital collecting my personal data, retaining this for a period of five years, and releasing this to the Resuscitation Council, UK and/or ALSG. I understand that this information will not be handed onto any other third parties.*

Must be ticked in order to proceed with form submission

I consent

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