EASTMAN DENTAL HOSPITAL SCHOOL OF DENTAL HYGIENE & DENTAL THERAPY STUDENT APPLICATION FORM PRIVATE & CONFIDENTIAL

PLEASE INDICATE WHICH TRAINING PROGRAMME YOU ARE APPLYING FOR:

PLEASE CHOOSE ONE TRAINING PROGRAMME ONLY

DENTAL HYGIENE1
SINGLE DIPLOMA (HYGIENE) 24 MONTHS

DENTAL THERAPY2
COMBINED DIPLOMA (HYGIENE & THERAPY) 27 MONTHS

COMMENCING: SURNAME:

SEPTEMBER 2013 FIRST NAME:

PLEASE COMPLETE THIS FORM IN BLACK INK

PLEASE COMPLETE ALL SECTIONS OF THIS APPLICATION FORM AS ONLY THIS FORM WILL BE SUBMITTED TO THE SELECTION PANEL. DO NOT ENCLOSE A SEPARATE C.V. DO NOT PRINT FORM DOUBLE-SIDED DO NOT WRITE ON THE BACK PAGES DO NOT ALTER THE FORMATTING OF DOCUMENT PLEASE ENSURE THAT YOU PROVIDE PHOTOCOPIES OF CERTIFICATES OF ALL RELEVANT ACADEMIC AND PROFESSIONAL QUALIFICATIONS WITH YOUR APPLICATION. PLEASE DO NOT INCLUDE COPIES OF CERTIFICATES UNRELATED TO THIS APPLICATION PLEASE DO NOT INCLUDE ANY OCCUPATIONAL HEALTH DATA WITH THIS APPLICATION ONLY QUALIFICATIONS FOR WHICH EVIDENCE IS PROVIDED WILL BE INCLUDED IN SCORING FOR SHORT-LISTING PLEASE ENSURE THAT YOUR APPLICATION FORM IS SENT TO ARRIVE ON OR BEFORE THE CLOSING DATE AS DETAILED IN THE PROSPECTUS AND ON THE UCLH WEBSITE. APPLICATIONS POSTED ON OR AFTER THE CLOSING DATE WILL NOT BE CONSIDERED
RETURN YOUR COMPLETED FORM AND SUPPORTING DOCUMENTATION TO:

ADMISSIONS OFFICE SCHOOL OF DENTAL HYGIENE & DENTAL THERAPY EASTMAN DENTAL HOSPITAL 256 GRAYS INN ROAD LONDON WC1X 8LD
FOR SOHT USE ONLY RECEIVED: ACKNOWLEDGED: ENTERED ONTO DB:

DO NOT EMAIL

PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED

-2ACKNOWLEDGEMENT OF RECEIPT OF APPLICATION FORM IS ELECTRONIC. AN EMAIL ADDRESS MUST BE PROVIDED

PERSONAL DETAILS SURNAME: MR MRS MISS MS FORENAME/S: MIDDLE NAME/S:

PLEASE SPECIFY OTHER PREVIOUS SURNAME/S: CURRENT ADDRESS

TO WHICH ALL COMMUNICATIONS WILL BE SENT

PERMANENT ADDRESS
ONLY COMPLETE THIS IF DIFFERENT FROM CURRENT ADDRESS OPPOSITE

POST CODE: HOME: WORK: MOBILE:

POST CODE: HOME: WORK: MOBILE:

: : :

: : :

REQUIRED

REQUIRED

E-MAIL ADDRESS:
MUST BE LEGIBLE

E-MAIL ADDRESS:
MUST BE LEGIBLE

ARE YOU OVER 18? EDUCATION:

YES

NO

NAME(S) OF MOST RECENT SCHOOLS | COLLEGES | UNIVERSITIES | EDUCATIONAL ESTABLISHMENTS ATTENDED (WITH DATES) FROM AGE 11 ( IN DATE ORDER):

NAME OF INSTITUTION MONTH

FROM YEAR MONTH

TO YEAR

PLEASE ENSURE YOU INCLUDE ALL EDUCATIONAL ESTABLISHMENTS, WHETHER YOU COMPLETED THE COURSE OR NOT

PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED

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- SECTION ONE ACADEMIC QUALIFICATIONS HELD

EXAMINATIONS FOR WHICH RESULTS ARE KNOWN. APPLICANTS MUST LIST ALL SUBJECTS TAKEN, WHATEVER THE RESULTS, IN CHRONOLOGICAL ORDER. GROUP TOGETHER ALL SUBJECTS TAKEN AT ONE SITTING. PLEASE CONTINUE ON A SEPARATE PAGE IF NECESSARY.

SUBJECT

LEVEL 1

DATE
MTH YEAR

GRADE 2

SUBJECT

LEVEL 1

DATE
MTH YEAR

GRADE 2

EG. GCSE | O | AS | A2 LEVELS | GNVQ | ACCESS | DIPLOMA | ACCESS | DEGREE, ETC. OR EQUIVALENT

VERIFICATION WILL BE REQUIRED

- SECTION TWO QUALIFICATIONS TO BE TAKEN | RESULTS PENDING (IF NONE, WRITE NONE) SUBJECT LEVEL DATE OF EXAMINATION MONTH YEAR

NOTE: REGARDING PENDING RESULTS: THE FULL COMPLETION OF ANY COURSE/S & ATTAINMENT OF QUALIFICATION/S IS MANDATORY IF YOUR APPLICATION RELIES ON PENDING RESULT/S, ANY OFFER OF A PLACE WILL BE CONDITIONAL ON THE FULL ATTAINMENT OF SAID QUALIFICATION

- SECTION THREE WERE YOUR ACADEMIC EDUCATIONAL QUALIFICATIONS DELIVERED IN ENGLISH? ONLY COMPLETE THIS SECTION YOUR ANSWER ABOVE IS NO
M ANDATORY REQUIREMENT: IELTS (PLEASE GIVE DETAILS OF YOUR IELTS)
IELTS SCORES READING WRITING LISTENING SPEAKING OVERALL DATE YES NO

DO YOU HOLD ANY OTHER ENGLISH LANGUAGE QUALIFICATION?

TITLE

SCORE

DATE

IF YOU ARE PLANNING TO TAKE AN ENGLISH LANGUAGE TEST, PLEASE GIVE DETAILS: TEST TO BE TAKEN: APPROX. DATE TO BE TAKEN:

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PROFESSIONAL QUALIFICATIONS HELD AWARDING BODY QUALIFICATION DATE OBTAINED PROFESSIONAL REGISTRATION NO.

FULL EMPLOYMENT HISTORY NAME OF:PRESENT OR MOST RECENT EMPLOYER POSITION

FULL OR PART TIME IF PART TIME,
STATE HOURS

FROM MONTH YEAR MONTH

TO YEAR

PAST EMPLOYMENT (MOST RECENT FIRST) NAME OF:PREVIOUS EMPLOYER(S) POSITION

FULL OR PART TIME IF PART TIME,
STATE HOURS

PLEASE CONTINUE ON A SEPARATE SHEET, IF NECESSARY

FROM MONTH YEAR

TO MONTH YEAR

PLEASE INDICATE THE EXPERIENCE YOU HAVE OF OBSERVING A DENTAL HYGIENIST AND / OR DENTAL THERAPIST IN A CLINICAL SETTING. THIS OBSERVATION MUST BE AS OUTLINED BY GENERAL DENTAL COUNCILS SCOPE OF PRACTICE FOR UK BASED DCPS DO NOT INCLUDE NAMES OF INDIVIDUALS.

TICK AS APPROPRIATE

General Practice

Specialist Practice

Community Trust

Hospital

Other

OBSERVATION OF A DENTIST WILL NOT BE ACCEPTED AS EQUIVALENT

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FURTHER INFORMATION | SUPPORTING STATEMENT

PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU CONSIDER IMPORTANT IN SUPPORT OF YOUR APPLICATION, INCLUDING ANY SPECIAL INTERESTS OR ACTIVITIES IN NO MORE THAN 600 WORDS. INDICATE YOUR WORD COUNT AT THE END OF THIS SECTION. THIS SECTION OF THE FORM IS SCANNED, THEREFORE, MUST BE TYPED. IF YOU EXCEED THE WORD COUNT WE WILL ASK YOU TO ADJUST AND RESUBMIT BEFORE CONSIDERATION. IT IS ACCEPTABLE TO SUBMIT THIS STATEMENT ON A SEPARATE A4 SHEET & APPEND TO YOUR APPLICATION. THIS AREA SHOULD NOT BE USED TO ADVISE OF ANY QUALIFICATION.

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REFERENCES Please give below the names and full contact details of two referees, including telephone number and e-mail address, if possible. At least one should be your present employer or current educational course lead, if you are a student. Your referees should be working with you at the present time and be able to comment on your suitability for a professional clinical training programme. You must not be related to whomever you nominate as a referee. Referees will automatically be approached if you are short-listed for interview; unless you specifically request otherwise. NAME OF REFEREE: JOB TITLE: ADDRESS: NAME OF REFEREE: JOB TITLE: ADDRESS:

POSTCODE TEL. NO.: FAX NO.: E-MAIL: Capacity of Referee:

Professional
INDICATE ACCORDINGLY BELOW

POSTCODE TEL. NO.: FAX NO.: E-MAIL: Capacity of Referee:

Professional
INDICATE ACCORDINGLY BELOW

Academic

Personal

Academic

Personal

May we approach this referee if you are short-listed? Yes No APPLICATION HISTORY

May we approach this referee if you are short-listed? Yes No

Is this your first application to the Eastman Dental Hospital, School of Dental Hygiene & Therapy? Yes No If no, please state in which year/s you made previous applications: Have you previously been interviewed at the Eastman for this programme? If yes, please state in which year/s you were interviewed:
ONLY ANSWER THE FOLLOWING QUESTION IF YOU HAVE BEEN INTERVIEWED OR HAVE APPLIED PREVIOUSLY

Yes

No

Have you gained additional qualifications/relevant experience since the most recent application or interview as stated above? IF YES, PLEASE PROVIDE BRIEF DETAILS Yes No

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DECLARATION PLEASE ENSURE ALL SECTIONS ARE COMPLETED 1. 2. I confirm that, to the best of my knowledge, the information given on this application form is correct and complete. I confirm that I have read the academic and non-academic entry requirements on pages 15 to 17 of the Prospectus and that I fulfil all these requirements to the best of my knowledge. I have read the School Prospectus and am aware of the attendance requirements for the training programme. I am enclosing copies of all relevant academic / professional qualifications.
PLEASE NOTE APPLICATIONS WILL NOT BE ACCEPTED WITHOUT THESE COPIES. IF THE ANSWER TO QUESTION 4 IS NO, PLEASE SUPPLY FULL DETAILS AS TO WHY THE COPIES ARE NOT ENCLOSED AND WHEN THESE WILL BE SUPPLIED. YES NO N/A

3. 4.

5. 6. 7.

I am enclosing certified translations for all documents not written in the English language, if applicable. I am enclosing UK NARIC Letters of Comparability for all qualifications attained overseas, if applicable. I will have been an UK/EU/EEA resident throughout the three year period preceding the first day of the training programme for which I am applying. (See Page 16 of Prospectus). This is to confirm your eligibility for an NHS funded place. Eligible students should have settled status under the immigration laws and have no restrictions upon their stay in the UK.

8.

I confirm that I have not been in receipt of NHS Funding for a Course in Dental Hygiene / Dental Therapy at any other School of Dental Hygiene & Dental Therapy If I accept a place on a training programme at another school of Dental Hygiene/Dental Therapy, College or University, I will withdraw this application (in writing). I understand that any offer of a place will be subject to occupational health clearance1, satisfactory references2 and a clear Enhanced Criminal Records Bureau Check.

9.

10.

SIGNATURE: DATE: DO NOT SUBMIT 1) ANY OCCUPATIONAL HEALTH CLEARANCE DOCUMENTATION 2) ANY REFERENCES
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THESE ITEMS WILL BE REQUESTED SEPARATELY (AT A LATER DATE)

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MONITORING INFORMATION This section of the application form is not made available during the short-listing process. The information collected is for monitoring purposes only and will help the organisation analyse the profile and make up of applicants and appointees to jobs in support of their equal opportunities policies. NHS organisations recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. We therefore welcome applications from all sections of the community. EQUALITY & DIVERSITY MONITORING

As Public Sector Employers, NHS organisations are required to collect details about an applicant's age and gender. This information is collected to fulfil that obligation and is used for monitoring purposes only.
DD MM YYYY

DATE OF BIRTH:

GENDER: MALE FEMALE I DECLINE TO ANSWER

EQUALITY ACT 2010 As Public Sector Employers, NHS organisations are required to collect details about an applicant's ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.
PLEASE INDICATE WHICH ETHNIC GROUP YOU BELONG TO:

WHITE BRITISH WHITE IRISH WHITE - ANY OTHER WHITE BACKGROUND ASIAN OR ASIAN BRITISH INDIAN ASIAN OR ASIAN BRITISH PAKISTANI ASIAN OR ASIAN BRITISH BANGLADESHI ASIAN OR ASIAN BRITISH - ANY OTHER ASIAN BACKGROUND MIXED - W HITE & BLACK CARIBBEAN MIXED - W HITE & BLACK AFRICAN MIXED - W HITE & ASIAN MIXED - ANY OTHER MIXED BACKGROUND BLACK OR BLACK BRITISH CARIBBEAN BLACK OR BLACK BRITISH AFRICAN BLACK OR BLACK BRITISH - ANY OTHER BLACK BACKGROUND OTHER ETHNIC GROUP CHINESE OTHER ETHNIC GROUP - ANY OTHER ETHNIC GROUP I DO NOT WISH TO DISCLOSE MY ETHNIC ORIGIN

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EQUALITY ACT 2010 In order to comply with these regulations NHS organisations are monitoring sexual orientation and religion/belief in applications. Please answer the following questions: Please indicate which term would best describe your sexual orientation:
LESBIAN GAY BISEXUAL HETEROSEXUAL I DO NOT WISH TO DISCLOSE MY SEXUAL ORIENTATION

Please indicate your religion or belief:

ATHEISM BUDDHISM CHRISTIANITY HINDUISM ISLAM JAINISM JUDAISM SIKHISM OTHER I DO NOT WISH TO DISCLOSE MY RELIGION OR BELIEF

The Equality Act 2010 protects disabled people - including those with long term health conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes - including the interview - are fair and equitable. Do you consider yourself to have a disability?
YES NO I DO NOT WISH TO DISCLOSE WHETHER OR NOT I HAVE A DISABILITY

Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark 'Other'. Physical Impairment Sensory Impairment Mental Health Condition Learning disability/difficulty Long-standing illness Other:

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CRIMINAL CONVICTIONS | REHABILITATION OF OFFENDERS ACT 1974 The Rehabilitation of Offenders Act (as amended) helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period, convictions are referred to as 'unspent' convictions and must be declared to employers. The NHS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion or belief, disability, sexual orientation and age. The NHS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory criminal record check. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment. Individuals applying for positions which involve 'regulated activity' are required to have an enhanced criminal record check and, where appropriate to the role, this check will also include any information which may be held against the barred lists for working with children and/or adults. The full definition of 'regulated activity' is defined in the Safeguarding Vulnerable Groups Act 2006, as amended by the Protection of Freedoms Act 2012 which came into force on 10 September 2012.

REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975 To protect certain vulnerable groups within society, there are a number of posts within the NHS that are exempt from the provisions of the Rehabilitation of Offenders Act 1974 (as amended). As the post you have applied for falls within this category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants for such posts are not entitled to withhold any information about convictions or other relevant criminal record information which for other purposes are 'spent' under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential and will be considered only in relation to posts to which the Order applies. All individuals applying for positions which involve 'regulated activity' are required to have an enhanced criminal record check and, where appropriate to the role, this check will also include any information which may be held against the barred lists for working with children and/or adults. The full definition of 'regulated activity' is defined in full under the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedoms Act 2012) which came into force on 10 September 2012.

PLEASE TURN OVER TO MAKE YOUR DECLARATION

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CRIMINAL CONVICTIONS DECLARATION Are you currently bound over, or do you have any unspent / spent convictions issued by a Court or Court Martial in the UK or any other country? YES NO If yes, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the Court hearing. Please note: you do not need to tell us about parking offences.

Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with children? YES NO If yes, please give details

Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with vulnerable adults? YES NO If yes, please give details

If you are related to, or have a relationship with a director or employee of an appointing organisation, please state the relationship:

YOUR NAME:

DATE OF APPLICATION: PROGRAMME APPLIED FOR: DENTAL HYGIENE DENTAL THERAPY

HOW DID YOU BECOME AWARE THAT THE PROGRAMME?

EASTMAN DENTAL HOSPITAL OFFERED THESE TRAINING

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