Apply for National Resuscitation Courses

Course applying for*

Name*

Prefix First Last

Name you wish to be known by

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

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

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