<p> M.258/504 THE UNIVERSITY OF HONG KONG FACULTY OF MEDICINE</p><p>Application for Admission as Occasional Student 2013 - 2015 (For taking individual modules under the Postgraduate Diploma in Child and Adolescent Health only)</p><p>The personal data provided in this form will be used for processing your application for enrolment on the relevant modules, by the administrative and academic departments concerned. If you wish to access or correct your personal data after submission of this form, please contact the Department of Paediatrics and Adolescent Medicine.</p><p>An attendance certificate will be issued to students who have attended both teaching sessions of the chosen modules.</p><p>This form should be completed and returned to the Department of Paediatrics and Adolescent Medicine [(Room 115, New Clinical Building, Queen Mary Hospital (Ref: PDipCAH))] together with a Hong Kong dollar cheque ($2,000 for each Module), which must be crossed and drawn in favour of "The University of Hong Kong". For enquiries, please contact Ms D Lai (Tel 2817 0641; Fax 2855 1523; email: [email protected]).</p><p>Section A </p><p>1. PERSONAL INFORMATION</p><p>Dr/Mr/Mrs/Miss* (Please fill in your full name [surname first] in block letters, as in your H.K.I.D. Card/passport.)</p><p>______Name in Chinese characters (if any): ______</p><p>Address for correspondence: ______</p><p>______</p><p>______</p><p>______</p><p>Fax No.: ______E-mail address: ______</p><p>Tel. No.: ______(Home) (Office) (Pager/Mobile Phone)</p><p>2. PRESENT OCCUPATION</p><p>Position held/Department ______Starting date ______</p><p>Name and address of organization ______</p><p>3. QUALIFICATIONS </p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>* Please delete as appropriate 4. COURSE ENROLMENT</p><p>(a) I wish to enroll in Module(s): _ </p><p>Module of Growth & Nutrition (19 & 20 October 2013) Module of Genetics & Family (22 & 23 February 2014) Module of Neuro-development & Neuro-habilitation (7 & 8 June 2014) Module of Infectious Diseases & Immunology (18 & 19 October 2014) Module of Community Child Health & Adolescent Health (13 & 14 December 2014) Module of Cardiorespiratory Health & Lifestyle (28 & 29 Mar 2015) Module of Paediatric Emergencies (13 & 14 June 2015) </p><p>(b) I will/will not* attend the examination at the end of each Module.</p><p>5. Total number of Module(s): ______</p><p>6. Total fee for the Module(s): ______</p><p>Bank Name: ______Cheque No.: ______Amount: HK$ ______</p><p>Date: ______Signature: ______</p><p>Notes:</p><p> Confirmation of enrolment will be issued 2 weeks before the commencement of the Module(s).</p><p> Official receipts will be issued by the Department of Paediatrics and Adolescent Medicine.</p><p>For Official Use Only </p><p>Section B </p><p>From : Academic Director of PDipCAH</p><p>To : Li Ka Shing Faculty of Medicine</p><p>I approve/do not approve* the application of this candidate for the study of the Module(s).</p><p>Remarks: ______</p><p>______</p><p>______</p><p>______</p><p>Date: ______Signature: ______</p><p>* Please delete as appropriate</p><p>May 2014</p>