Employment Application (2-Pp.) s13

5x1 DAFNE conversion training Application Form

Lead educator to complete section 1 and the disclaimer Participant to complete section 2, 3 and the disclaimer *Please refer to the T&C’s at the end of the application form for guidance notes

SECTION 1: LEAD EDUCATOR & CENTRE DETAILS Lead Educator’s Surname: Type here Lead Educator’s First Name: Type here

How many educators in your service are 5x1 DAFNE trained? Click here to *1 select Please enter the details of the Educators who are currently 5x1 DAFNE trained at your centre:

Type name of educator 1 Type name of educator 2 (if applicable)

Enter DAFNE Educator number Enter DAFNE educator number

Surname of participant: Type here First Name of participant: Type here Profession of Click here to select DAFNE educator number: Enter DAFNE educator number participant: Participant’s mobile Enter number Participant’s email address: Enter email address *2 number: DAFNE Centre: Select centre

Centre Address: Enter address

Town/ City: Enter town/city Postcode: Enter postcode

SECTION 2: PAYMENT METHOD Please select which payment method you would like to use to pay for the DAFNE resources and access to the online course (£90) *3:

Visa ☐ *4 Cheque ☐ *5 PO Number ☐ *6 Enter PO number

SECTION 3: POSTAL ADDRESS FOR RESOURCES Please supply the address you would like your 5x1 resources posted to, if the address is different to your work address. Please consider that resources will be delivered via courier between the hours of 09:00 – 17:00 and must be signed for access to the online system is granted *7. Address Click here to enter text.

Town/ City Click here to enter text. Postcode Click here to enter text.

DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. I have also read, understood and agree to the T&Cs attached

Lead Educator’s signature: Date Select Participant’s signature: Date Select

RETURN APPLICATION & CENTRAL DAFNE CONTACT DETAILS Email *8 (preferred method) to: Post to: Fax to: 0191 2934276 Central DAFNE, Diabetes Resource Centre, North Tyneside General Hospital, [email protected] Rake Lane, North Shields, Tyne and Wear , Any queries telephone: 0191 2934115 NE29 8NH T&C’s

*Notes

T20.002, version 1 – March 2017 1 You can only apply for a participant to undertake the 5x1 DAFNE training if there is at least 1 other educator currently 5x1 trained within your service. If you don’t have any educators 5x1 DAFNE trained, please submit applications for 2 participants.

2 The email address must be an NHS email account. We can’t supply access to private email addresses.

3 The payment total consists of £40 for DAFNE resources and £50 fee for access to the online system. Please note this fee is non- refundable.

4 If paying by Debit/Credit card please contact the central DAFNE team on 0191 2934115; the payee will be transferred to NHCT finance department to process payment.

5 If paying by cheque, please make payable to Northumbria Healthcare NHS Foundation Trust.

6 If paying by this method, please remember to enter the PO number onto your application form in order to proceed.

7 We will email you to notify once your application has been processed and your resources have been posted to you, it is essential that you notify us within 7 working days if you do not receive your resources, failure to do so will mean we are unable to accept responsibility.

8 If you are returning your application form via email, we can accept the application form along with email trails of approval from both parties in replace of a handwritten signature, providing the emails are from NHS email accounts.

T20.002, version 1 – March 2017