Health Champion Course Enrolment Form

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Thank you for purchasing this course. We now require information about the learner to enrol them on the programme.

The data you provide on this form will be used by Pharmacy Complete for administrative and statistical purposes relating to this course. It will be used in accordance with the relevant legislation, including the UK General Data Protection Regulation and the Data Protection Act 2018. By submitting this personal data, you are giving your consent for it to be used for these purposes.

If you have any questions about the use of the data collected here, please check our privacy policy and our terms and conditions at pharmacycomplete.org or contact us at admin@pharmacycomplete.org

Learner's full name *

Learner's title *

Learner's Date of Birth (required for RSPH registration) *

YYYY

Learner's email (optional)

Learner's Ethnicity *

Disability? Yes/No? - if yes please confirm what *

Registered Disabled? *

Yes

Learning support required? *

Yes

Pharmacy name *

Pharmacy address and postcode *

Pharmacy telephone number *

Pharmacy email *

Name of invigilating Pharmacy Professional (Must be a GPhC registrant and not related to the learner) *

Invigilator's GPhC number *

Submit

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