Netcare Paramedic Application Form – Fill Out and Use This PDF

SCHOOL OF EMERGENCY
SECCAND CRITICAL CARE
	REGISTRATION FORM
GAUTENG: Midrand	KWAZULU NATAL: Umhlanga Rocks	MPUMALANGA: Nelspruit
Riverview Ofice Park	95 Umhlanga Rocks Drive	Sonpark, Piet Retief Road
410 Janadel Avenue	Umhlanga Rocks	Nelspruit
TEL: (010) 209 8383	TEL: (031) 581 8209	TEL: (013) 741 1620
Fax: 086 638 8072	Fax: (031) 581 8247	Fax: (013) 741 2292
e-mail: seccenquiries@netcare.co.za	e-mail: seccenquiries@netcare.co.za	e-mail: seccenquiries@netcare.co.za

Please note:

Please• Fullnote:tuition fees are payable upfront with registration, at least one week before the commencement date of the course.

•FullNotuitionpart paymentfees areorpayableinstallmentsupfrontwillwithberegistration,considered. atShouldleast onethe fullweekcoursebeforeethenotcommencementbe deposited withindatethisof thepericoursed, your. provisional booking will be

Nodeemedpart paymentnull andorvoidinstallments. will be considered. Should the full course fee not be deposited within this period, your provisional booking will be

•deemedAll feesnullmustandbevoid.paid via direct bank deposit or electronic transfer.

••AllNofeescashmustpaymentsbe paidarevia accepteddirect bankatdepositany of theor electroniccampusestransfer. .

••NoNocashapplicationpaymentsformarewillaccbeacceptedat anyandof theno bookingscampuseswill. be made unless proof of payment is attached thereto.

••NoAllapplicationrequired documentsform will bemustacceptedbe attachedndnotobookingsthe registrationwill be madeformbeforeunlessitproofwill beof processedayment is. attached thereto.

SECTION A: PERSONAL INFORMATION

Surname:

Gender:

Male

Female

First name:

Middle initial:

Title: Prof Dr Sr

Mr Mrs

Ms

Other

Calling name (for name tag):

ID Number:

Race (circle your choice):

Asian

Black

Coloured

White

Employee Number:

Address (Work):

Postal code:

Address (Home):

Postal code:

Preferred postal address:

Postal code:

Telephone numbers: Work (code

Home (code

)

)

Fax numbers:

Work (code

Home (code

)

)

Cellular telephone number:

E-mail address:

Medical aid details (please attach a copy of your membership card):

SECTION B: COURSE INFORMATION

Name of course:

HPCSA number (If appliccable):

Course start date:Course end date:

SECTION C: CANCELLATION OF REGISTRATION

The following cancellation rules apply once a student has been accepted onto the programme:

1.A student shall advise the School of Emergency and Critical Care (SECC) in writing of his/her intention to cancel this registration in full or in part.

2.No cancellation of registration in full or in part shall be of force or effect without written conirmation thereto by an authorised oficer of the SECC.

3.All student registrations are for a complete course. Should a student choose not to continue his/her studies at any point, they are required to immediately inform the programme administrators in writing. The SECC does not take responsibility for cancellations communicated verbally or not submitted to the Administration Ofice.

4.A student who cancels his/her registration shall incur inancial liability in terms of fees according to the cancellation rules speciied below.

5.Where a student is registered provisionally, pending submission of outstanding documentation, the registration shall be cancelled if the outstanding documents are not submitted prior to the course start date. Such a student shall be liable for payment of fees in respect of all the table below.

Cancellation rules for all SECC courses:

Please note: All registrations for BAA, AEA, CCA, ACLS, ITLS and PALS courses are subject to a non-refundable processing fee of R500.

Date of receipt of written notiication of cancellation	Cancellation fees
20 working days or more before course commences	R500 rebate
Less than 20 working days before course commences	Liable for 50% of total tuition fees
From the irst date of the course commencing	Liable for full tuition fees

SECTION D: DECLARATION AND UNDERTAKING

All applicants and their sponsors (person responsible for payment) must complete and sign this section.

I understand that the School of Emergency and Critical Care (SECC) reserves the right to decline the application if it does not meet entry criteria.

I understand that applicants will be required to take and pass an entry examination by way of a selection process for the BAA, AEA and CCA courses, which is subject to a non-refundable entry examination fee of R350.

I understand that payment of the course fee does not automatically guarantee a course certiicate at the culmination of the course.

I understand that the School of Emergency and Critical Care (SECC) reserves the right to cancel courses for whatever reason, in which event money paid to the School of Emergency and Critical Care (SECC) will be refunded upon request, of held over until the next course is run.

SECTION E: INDEMNITY AND WAIVER

All applicants must complete and sign this section

hereby indemnify the Netcare 911 School of Emergency and Critical Care (SECC) and its employees, representatives, instructors or agents against any claim or claims for compensation or damage, loss or injury, fatal or otherwise, however arising, including but not limited to any acts, omissions or default, sustained during the course of any of the theoretical, operational or practical aspects of the training exercises, caused directly or indirectly to me or my belongings/properties, which indemnity shall extend to my dependants, estate or any person, whomsoever, as well as against any damage which the Netcare 911 School of Emergency and Critical Care (SECC), its instructors, servants, representatives or agents may suffer through any of my acts or omission however caused, and I hereby unconditionally waiver any right that I may have against the Netcare 911 School of Emergency and Critical Care (SECC), its principals, instructors, servants, representatives or agents to claim damages of whatsoever nature however caused.

I accept that I will be undertaking any instruction, tasks or exercises at my own sole risk and peril.

I accept that this indemnity extends further to cover the re-imbursement for all legal and other expenses that may be incurred by Netcare 911 School of Emergency and Critical Care (SECC) in examining, litigation, or settling any such claim.

Thus done and signed at							on this the		day of
in the year				in the presence of the undersigned witness.
As witnesses:
1.)
	(Sign here)					(Provide name in print)
2.)
	(Sign here)					(Provide name in print)

SECTION F: CONTACT DETAILS OF NEXT OF KIN

SECTION G: SCHOOL OF EMERGENCY AND CRITICAL CARE (SECC) BANKING DETAILS Please fax a copy of the deposit slip, as proof of payment, along with your registration form to:

SECC Administrator	SECC Administrator	SECC Administrator
Gauteng Campus	KwaZulu Natal Campus	Mpumalanga Campus
Fax: 086 638 8072	Fax: (031) 581 8247	Fax: (013) 741 2292

Please quote your initial, surname and reference the campus you will be attending your course at (Midrand, KZN or Nelspruit) as the reference number on your deposit slip.

Netcare 911 School for Emergency and Critical Care banking details are as follows:

Bank: Nedbank

Branch: Sandown

Branch code: 193305 Account type: Cheque

Account no: 1933 186 763