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Course applying for
*
--- Please select ---
EPALS 17/18 November 2022
ALS 14/15 September 2022
ALS 22/23 November 2022
NLS 30th November 2022
APLS 20/21 October 2022
APLS 15/16 December 2022
eALS 21 July 2022
eALS 17 August 2022
eALS 6 September 2022
eALS 5th October 2022
eALS 6th December 2022
GIC - 2/3 November 2022
Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Last
Name you wish to be known by
Preferred pronoun
he/him
she/her
they/them
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
Specific dietary requirements
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
Δ
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