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Dental Nursing Course - Application Form
Personal Information
Name
Telephone
Email
Address
Date of Birth
NI Number
Emergency Contact Details
Photo ID
One file only.
4 MB limit.
Allowed types: gif, jpg, png, svg, jpeg.
ID & Certification Documents
Maximum 5 files.
4 MB limit.
Allowed types: gif, jpg, png, pdf.
Employment
Practice Name / Address
Are you currently employed at least 16 hours per week at chair side?
Yes
No
Within this role are you being paid at least the National Minimum Wage?
Yes
No
Have you been provided with a contract of employment?
Yes
No
Do you have use of a laptop or tablet? (MS Word is required for your work production on the eportfolio system)
Yes
No
Equal Opportunities Data
Gender
Male
Female
Prefer not to say
Do you have any learning difficulties and/or health problems which affect your ability to carry out day-to-day activities?
Yes
No
Visual Impairment
Yes
No
Hearing Impairment
Yes
No
Disability affecting mobility
Yes
No
Other physical disability
Yes
No
Other (e.g epilepsy, asthma, diabetes)
Yes
No
Emotional / behavioural difficulties
Yes
No
Mental health difficulty
Yes
No
Profound complex disabilities
Yes
No
Asperger's Syndrome
Yes
no
Dyslexia
yes
no
Dyscalculia
Yes
no
Autism spectrum disorder
Yes
No
Multiple learning difficulties
Yes
No
Other
Yes
no
Extra
Language Skills
Is English your first language?
Yes
No
If no, what is your first language?
What level of English have you previously studied at?
Ethnicity
Mark which box best describes you:
White British - English/Welsh/Scottish/Irish
White - Gypsy/Irish Traveller
White - Any other traveller
Mixed - White & Black Caribbean
Mixed - White & Black African
Mixed - White & Asian
Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistan
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Any other Asian background
Black or British black - African
Black or British black - Caribbean
Any other
I understand that there is an employment requirement to be immunised against Hepatitis B to work as a dental nurse and that this must be arranged before the start of any clinical setting
Leave this field blank
