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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 GRAY’S 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. 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 . 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.

ANY OFFER OF A PLACE WILL BE CONDITIONAL ON THE FULL ATTAINMENT OF SAID QUALIFICATION . DATE TO BE TAKEN: PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED . GROUP TOGETHER ALL SUBJECTS TAKEN AT ONE SITTING.-3- . SUBJECT LEVEL 1 DATE MTH YEAR GRADE 2 SUBJECT LEVEL 1 DATE MTH YEAR GRADE 2 1 EG. OR EQUIVALENT 2 VERIFICATION WILL BE REQUIRED . 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. ETC.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. APPLICANTS MUST LIST ALL SUBJECTS TAKEN. PLEASE GIVE DETAILS: TEST TO BE TAKEN: APPROX. PLEASE CONTINUE ON A SEPARATE PAGE IF NECESSARY. IN CHRONOLOGICAL ORDER. GCSE | O | AS | A2 LEVELS | GNVQ | ACCESS | DIPLOMA | ACCESS | DEGREE.SECTION ONE – ACADEMIC QUALIFICATIONS HELD EXAMINATIONS FOR WHICH RESULTS ARE KNOWN. WHATEVER THE RESULTS.SECTION TWO QUALIFICATIONS TO BE TAKEN | RESULTS PENDING (IF NONE.

TICK AS APPROPRIATE General Practice Specialist Practice Community Trust Hospital Other OBSERVATION OF A DENTIST WILL NOT BE ACCEPTED AS EQUIVALENT PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED . 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. FULL EMPLOYMENT HISTORY NAME OF:PRESENT OR MOST RECENT EMPLOYER POSITION FULL OR PART TIME IF PART TIME. STATE HOURS PLEASE CONTINUE ON A SEPARATE SHEET. THIS OBSERVATION MUST BE AS OUTLINED BY GENERAL DENTAL COUNCIL’S SCOPE OF PRACTICE FOR UK BASED DCPS DO NOT INCLUDE NAMES OF INDIVIDUALS.-4- PROFESSIONAL QUALIFICATIONS HELD AWARDING BODY QUALIFICATION DATE OBTAINED PROFESSIONAL REGISTRATION NO. 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 AREA SHOULD NOT BE USED TO ADVISE OF ANY QUALIFICATION. THIS SECTION OF THE FORM IS SCANNED. THEREFORE. IF YOU EXCEED THE WORD COUNT WE WILL ASK YOU TO ADJUST AND RESUBMIT BEFORE CONSIDERATION. MUST BE TYPED. PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED .-5- FURTHER INFORMATION | SUPPORTING STATEMENT PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU CONSIDER IMPORTANT IN SUPPORT OF YOUR APPLICATION. IT IS ACCEPTABLE TO SUBMIT THIS STATEMENT ON A SEPARATE A4 SHEET & APPEND TO YOUR APPLICATION. INDICATE YOUR WORD COUNT AT THE END OF THIS SECTION. INCLUDING ANY SPECIAL INTERESTS OR ACTIVITIES IN NO MORE THAN 600 WORDS.

including telephone number and e-mail address.: E-MAIL: Capacity of Referee: Professional INDICATE ACCORDINGLY BELOW POSTCODE TEL. Referees will automatically be approached if you are short-listed for interview. NO. unless you specifically request otherwise. School of Dental Hygiene & Therapy? Yes No If no.: FAX NO. if you are a student.: 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. You must not be related to whomever you nominate as a referee.-6- REFERENCES Please give below the names and full contact details of two referees. if possible. 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 PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED .: FAX NO. NAME OF REFEREE: JOB TITLE: ADDRESS: NAME OF REFEREE: JOB TITLE: ADDRESS: POSTCODE TEL. At least one should be your present employer or current educational course lead. 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. NO. please state in which year/s you made previous applications: Have you previously been interviewed at the Eastman for this programme? If yes.

if applicable. if applicable. 8. 4. 7. satisfactory references2 and a clear Enhanced Criminal Records Bureau Check. 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. 6. Eligible students should have settled status under the immigration laws and have no restrictions upon their stay in the UK. I have read the School Prospectus and am aware of the attendance requirements for the training programme. (See Page 16 of Prospectus). SIGNATURE: DATE: DO NOT SUBMIT 1) ANY OCCUPATIONAL HEALTH CLEARANCE DOCUMENTATION 2) ANY REFERENCES PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED THESE ITEMS WILL BE REQUESTED SEPARATELY (AT A LATER DATE) . PLEASE SUPPLY FULL DETAILS AS TO WHY THE COPIES ARE NOT ENCLOSED AND WHEN THESE WILL BE SUPPLIED. College or University. PLEASE NOTE APPLICATIONS WILL NOT BE ACCEPTED WITHOUT THESE COPIES. I am enclosing UK NARIC Letters of Comparability for all qualifications attained overseas.-7- DECLARATION PLEASE ENSURE ALL SECTIONS ARE COMPLETED 1. 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. 9. IF THE ANSWER TO QUESTION 4 IS NO. I am enclosing certified translations for all documents not written in the English language. 10. I understand that any offer of a place will be subject to occupational health clearance1. 5. I will withdraw this application (in writing). This is to confirm your eligibility for an NHS funded place. I confirm that. YES NO N/A 3. I am enclosing copies of all relevant academic / professional qualifications. 2. the information given on this application form is correct and complete. to the best of my knowledge. 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.

ANY OTHER ETHNIC GROUP I DO NOT WISH TO DISCLOSE MY ETHNIC ORIGIN PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED .ANY OTHER WHITE BACKGROUND ASIAN OR ASIAN BRITISH – INDIAN ASIAN OR ASIAN BRITISH – PAKISTANI ASIAN OR ASIAN BRITISH – BANGLADESHI ASIAN OR ASIAN BRITISH .W HITE & BLACK AFRICAN MIXED .ANY OTHER MIXED BACKGROUND BLACK OR BLACK BRITISH – CARIBBEAN BLACK OR BLACK BRITISH – AFRICAN BLACK OR BLACK BRITISH . race.W HITE & BLACK CARIBBEAN MIXED .ANY OTHER BLACK BACKGROUND OTHER ETHNIC GROUP – CHINESE OTHER ETHNIC GROUP . This information is collected to fulfil that obligation and is used for monitoring purposes only. EQUALITY & DIVERSITY MONITORING As Public Sector Employers. NHS organisations are required to collect details about an applicant's age and gender. 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. NHS organisations are required to collect details about an applicant's ethnicity. pregnancy and maternity. religion or belief. 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 . gender reassignment. disability. We therefore welcome applications from all sections of the community. DD MM YYYY DATE OF BIRTH: GENDER: MALE FEMALE I DECLINE TO ANSWER EQUALITY ACT 2010 As Public Sector Employers.-8- MONITORING INFORMATION This section of the application form is not made available during the short-listing process. marriage and civil partnership. sex and sexual orientation.W HITE & ASIAN MIXED . 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.ANY OTHER ASIAN BACKGROUND MIXED .

please mark 'Other'. learning disabilities and so called "hidden" disabilities such as dyslexia.including those with long term health conditions. 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 . 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. If none of the categories apply. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes . in which case you may indicate more than one. People may experience more than one type of impairment.including the interview .-9- EQUALITY ACT 2010 In order to comply with these regulations NHS organisations are monitoring sexual orientation and religion/belief in applications. Physical Impairment Sensory Impairment Mental Health Condition Learning disability/difficulty Long-standing illness Other: PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED .are fair and equitable.

If you are successful with this application. The NHS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment. REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975 To protect certain vulnerable groups within society. The NHS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. any failure to disclose such information could result in dismissal or disciplinary action. Individuals applying for positions which involve 'regulated activity' are required to have an enhanced criminal record check and. PLEASE TURN OVER TO MAKE YOUR DECLARATION PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED . The full definition of 'regulated activity' is defined in the Safeguarding Vulnerable Groups Act 2006. disability. All individuals applying for positions which involve 'regulated activity' are required to have an enhanced criminal record check and. this check will also include any information which may be held against the barred lists for working with children and/or adults. your offer of employment may be subject to a satisfactory criminal record check. 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 2012.10 - 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'.. If you are applying for a post involving access to persons in receipt of health services. gender. As the post you have applied for falls within this category. religion or belief. 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. marital status. this check will also include any information which may be held against the barred lists for working with children and/or adults. convictions are referred to as 'unspent' convictions and must be declared to employers. 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. where appropriate to the role. as amended by the Protection of Freedoms Act 2012 which came into force on 10 September 2012. During the rehabilitation period. where appropriate to the role. Any information provided will be confidential and will be considered only in relation to posts to which the Order applies. there are a number of posts within the NHS that are exempt from the provisions of the Rehabilitation of Offenders Act 1974 (as amended). sexual orientation and age.

. and the date and place of the Court hearing. Please note: you do not need to tell us about parking offences. please give details  If you are related to. please include details of the order binding you over and/or the nature of the offence. the penalty. 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 PLEASE DO NOT WRITE ON THE BACK OF THIS PAGE PLEASE DO NOT PRINT THIS FORM DOUBLE-SIDED . 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. or have a relationship with a director or employee of an appointing organisation. sentence or order of the Court. 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.11 - CRIMINAL CONVICTIONS DECLARATION  Are you currently bound over.  Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with children? YES NO If yes.