General Optical Council STUDENT REGISTRATION Application Form
Total Page：16
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General Optical Council STUDENT REGISTRATION Application form Please read the attached guidance notes and complete the form in full. This form is for applicants who wish to register as a student optometrist or student dispensing optician with the General Optical Council (GOC). This form can be typed onto however there are sections that must be completed in writing. These sections will be marked with this symbol. If you are completing this form by hand, complete it with a black pen and in block capitals. For more information about registering as a student with the GOC please visit our website: www.optical.org/en/Registration/Applying_for_registration/Students.cfm If you are not completing an accredited training course as listed on our website please fill out this form but leave section 2 blank. We will contact you to confirm what training you are undertaking. If you require any assistance completing your registration form please contact the registration team at [email protected] or on 020 7580 3898 (option 1). What happens next? Once your form is submitted, approved and payment received you will join the student register. We will confirm this by email along with details of your GOC number and how to access your MyGOC account (the registrant only area of our website). SR001 08/16 Page 1 Checklist Please complete all sections of the application form and read the guidance notes before completing the form. Have you selected an option from Student Optometrist or Student Dispensing Optician? Section 1 – Contact details Have you provided your full name, DOB, an email address and selected your registered address? Section 2 – Education establishment Have you entered the start date against the relevant educational establishment? Section 3 – Declarations Have you completed this section? If you ticked yes, have you provided details including relevant documentation? Section 4 – Identification Has the person certifying your identification also signed this application form where indicated? Section 5 – Declaration of information Have you read, signed and dated the application? Section 6 – Payment Have you provided payment details? Guidance notes and monitoring form Have you read the guidance notes before completing the form? An equality, diversity and inclusion monitoring form is enclosed. The information you provide will help us to assess impact and advance the promotion of equality and diversity in the work that we do. Supporting documents Please ensure you include the following documents with your application. Proof of identity Payment (if paying by cheque) Please do not send originals to the GOC. It is your responsibility to ensure that your registration form arrives at the GOC and that your name is entered on the GOC register. Page 2 Student registration form Select the register you are applying for: Student optometrists Student dispensing opticians Section 1 – Contact details Your full name, home town and practice address (if provided) will appear on the public register and may be available to third parties. We need your full name, DOB, a physical address, and a contact email address and telephone number so that we can easily contact you about your registration.' Which of the following would you like as your registered address with the GOC to be used for correspondence? Home Practice If you do not tick a box we will use your home address as your registered address. Title (please tick) Mr Mrs Ms Miss First name(s) Surname Date of birth DD// MM YYYY Email (confirmation of registration will be sent to this email address) Full home address Post code Telephone number Is this address also a practice address? Yes – if so, this address will appear on the published register. No Practice where you are undertaking practical experience (if applicable). To be completed in full if different from contact address above. Please attach an extra page for any additional practice addresses. Name of practice Full address Post code Telephone number Page 3 Section 2 – Educational establishment where you are undertaking optical training Please indicate the name of your approved educational establishment by noting the start date in format MM/YYYY in the ‘Start Date’ column. The GOC will contact the educational establishment directly to confirm which course you are enrolled in. A list of the GOC accredited and provisionally approved training courses are on the Education section of our website. If you are not completing a training course at one of the educational establishments listed below please fill in the supervision section at the bottom of this page. Student optometrists Start date Anglia Ruskin University MM Y Y Y Y Aston University, Birmingham MM Y Y Y Y Cardiff University MM Y Y Y Y City University, London MM Y Y Y Y Glasgow Caledonian University MM Y Y Y Y Plymouth University MM Y Y Y Y The College of Optometrists MM Y Y Y Y University of Bradford MM Y Y Y Y University of Hertfordshire MM Y Y Y Y University of Manchester MM Y Y Y Y University of Portsmouth MM Y Y Y Y University of Ulster MM Y Y Y Y Student dispensing opticians Start date Anglia Ruskin University M MYYYY Association of British Dispensing Opticians (ABDO) College M MYYYY ABDO College with Canterbury Christ Church University M MYYYY ABDO Examinations M MYYYY Bradford College M MYYYY City and Islington College M MYYYY City University London M MYYYY Glasgow Caledonian University M MYYYY Only fill in your supervisor's details if you are not attending one of the educational establishments listed above. Supervisor’s full name Supervisor’s GOC Number Supervisor’s practice address (if different from the practice address in section 1): Name of practice Full address Post code Telephone number Page 4 Section 3 – Fitness to train declarations Do you wish to make any declarations? Yes Please give full details below Failure to provide full details will delay your application No Please proceed to Section 4 The GOC website provides further guidance in the Registration section under ‘Making declarations’. Criminal matters Please provide details of any conviction in the British Isles or abroad, caution, conditional caution, conditional discharge, absolute discharge or Social Security Administration Act penalty in the British Isles; any agreed offer, penalty payment agreement or absolute discharge order in Scotland; and any investigation or proceedings that could lead to any of the previous outcomes. You must provide details of the date, offence, name of court, any penalty or punishment (including the amount of any fine) and background circumstances. Attach a separate sheet if necessary. You must provide full details of any conviction or caution that is ‘spent’ under the Rehabilitation of Offenders Act 1974, unless it is a ‘protected’ caution or conviction. You do not need to declare any road traffic offences that have been dealt with by way of a fixed penalty but you must provide full details of any road traffic offences that have resulted in a conviction. Disciplinary matters Please provide details of any determination by the GOC or another body that regulates a health or social care profession either in the UK or abroad, including an NHS Primary Care Organisation or health board; any investigation or proceedings that could lead to a determination by another such regulator; and any breach of the GOC’s Code of Conduct and/or Standards of Practice for individual registrants. You must provide details of the date, incident, name of other regulator, any sanction and background circumstances. Attach a separate sheet if necessary. Page 5 Physical and mental health Please provide details of any physical or mental health conditions that, in the view of a reasonable person, might currently affect your fitness to train. You must provide details of the date, nature of the condition, diagnosis and any treatment required. Section 4 – Identification You need to provide one of the following forms of identification with this application: 1. A clear, in colour and certified photocopy of one of the following valid documents: passport, student ID, or UK driver's licence OR 2. A passport sized colour photograph certified with a signature and name of the person signing it on the back. You need to ask a professional person or someone of good standing in your community who has known you for at least two years to certify your chosen form of identification. This can be an optometrist or dispensing optician, solicitor or notary, dentist, teacher or lecturer, or chartered accountant. The person should not be related to you or living at the same address. Instructions for the person certifying your document Once you have the coloured photocopy and original of the applicant's identification document, please complete the following steps on the photocopied document. 1. Write ‘Certified to be a true copy of the original seen by me’ on the document 2. Sign and date 3. Print your name under the signature 4. Adding your occupation, address and telephone number. If the applicant has provided a passport sized photograph instead of a photocopied document please sign and write your name on the back of the photograph. You must also complete this section in writing. I certify that I have known the applicant for at least for at least two years and that the attached identification, which is certified by me is a true likeness. Name of applicant Name of person certifying Position of person certifying Professional registration number of person certifying (if applicable) Signed Date Page 6 Section 5 – Declaration of information - Applicant must sign I declare that I have read, understood and will comply with the GOC’s Standards for Optical Students. I declare that the information given in this form is true and accurate. I understand which information I have provided (within section 1) will be published on the register and made available to third parties on request and agree to the GOC using the information I have provided to exercise its proper and statutory functions which include updating the register, administering and maintaining registration, processing complaints and compiling statistics or research, in line with the Data Protection Act 1998 (DPA).