Enrolment Form Course: Accredited Checking …

1 Enrolment Form course : Accredited Checking pharmacy technician course Please complete all fields, in capitals and delete where appropriate Candidate details: As a candidate you must fulfil the following criteria: Be a registered pharmacy technician (unless you work in Northern Ireland). Have worked at least 6 months in your current workplace Have demonstrated your ability to dispense accurately in your current workplace (Note should you leave your current workplace during the course , we have the right to withdraw you from the course as you may not be able to satisfy the course requirements in a different location). First name*: Last name: Title: Mr / Mrs / Miss / Ms / Dr Gender: Male / Female Email address: Date of Birth: Are you registered disabled? Yes / No Do you consider yourself to have a disability? Yes / No Do you wish to discuss any needs for additional support with a member of Buttercups staff? Yes / No Ethnicity (select ONE only): Asian or Asian British: Chinese / Bangladeshi / Indian / Pakistani / Other Asian Background Black or Black African: African / Caribbean / Other black background White: British / Irish / Other white background Mixed: White and Asian / White and black African / White and black Caribbean / Any other *This is your full legal name that will appear on your certificate.

2 Company details: Company name: Company address: Post code: Tel: Fax: Email address: Working hours: Invoice address if different from above: Company name: Invoicing address: Post code: Tel: Fax: Delivery of the course : This course is available to complete either as a paper version, or can be accessed on-line: Please indicate how you would like this course to be delivered: Paper Version / On-Line Buttercups Training Ltd 1-2 The Courtyard, Main Street, Keyworth, Nottinghamshire, NG12 5AW 1 of 2. Facilitator Information: As a facilitator you must fulfil the following criteria: Be a registered Pharmacist, or an ACPT ( Accredited Checking pharmacy technician ) with at least three years'. post qualification experience. Be able to meet regularly with the candidate during their training Please tick the declarations below: I confirm that the applicant has demonstrated dispensing accuracy to a level satisfactory for this organisation I confirm that the applicant meets the criteria to undertake this course (listed on the previous page).

3 I confirm that I meet the criteria listed above to act as facilitator Medication errors training for facilitators We strongly advise our facilitators to complete a training pack on medication errors. If you have previously acted as a facilitator for a Buttercups accuracy Checking course then you may already have completed one and there is no need to repeat this. However, if you are a first time facilitator then please tick here and we will provide you with online access and you will be certificated on completion. Designated facilitator name: Signature of facilitator: Date: Position held: GPhC registration number: Email address: If an ACPT, please enclose a copy of your current certificate Data protection consent: Under UK and European Data Protection legislation, data from which living individuals can be identified are classed as 'personal data'. The handling of personal data has to comply with legal requirements covering such things as the way in which this information is acquired, how it is processed and the extent to which it is disclosed or transferred to others.

4 Buttercups Training needs to store data about you and your course progress. The data you provide on this form will be used by Buttercups Training for administrative and statistical purposes. By submitting your personal data you are giving your consent for it to be used for these purposes. It will be used in accordance with the relevant legislation, including the Data Protection Act 1998. If you have any questions about the use of the data collected here or other personal information, please contact Buttercups Training on 0115 937 4936. Please fill in this form and return it to Buttercups Training to consent to us storing your data electronically. I hereby give my consent to the storage of personal information about me and my course progress. I understand that this information may remain available and in storage after I have finished my course of study. Name of Candidate: GPhC Registration Number: (Not required if in Northern Ireland). Signature of Candidate: Date: Buttercups Training Ltd 1-2 The Courtyard, Main Street, Keyworth, Nottinghamshire, NG12 5AW 2 of 2.