Marymount - Course Application Form Course Details:Please select the course / programme you wish to apply for:(Required)Fundamental Aspects of Palliative CareAn Introduction to Palliative care for Health Care AssistantsSyringe Pump Use In Palliative CareDignity in Care workshopCourse Date:(Required)Select Date22/10/202427/11/202415/01/202513/03/202515/05/202301/07/202524/09/202525/11/2025Course Date:(Required)Select Date30/04/2025Course Date:(Required)Select DateCourse Date:(Required)Select Date23rd – 24th March 2023Your Details:Title:(Required)Select TitleMrMrsMsDrName:(Required) First Last Home Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Telephone Number:(Required)Email Address:(Required) Current Employer Details:Name of employer:(Required) Work Address:(Required) Setting:(Required)select settingHospiceAcute HospitalCommunity HospitalNursing HomeCommunity Care TeamYour current role:(Required) Professional Body:(Required)select bodyNMBIRCPICORUOtherNoneProfessional Body ( Unlisted)(Required) Please supply your professional registration PIN here:(Required) (If not applicable to your application please enter - N/A)Cancellations: 14 days-notice is needed to cancel your registration in order to receive a full refund (Minus a €20.00 Admin fee). If cancellation is less than 14 days you may only receive a 50% refund. Each case will be reviewed on an individual basis taking any unforeseen circumstances preventing your attendance into account. Marymount University Hospital and Hospice reserve the right to cancel a programme, in which case a full refund will be issued. Data Protection: In accordance with the Data Protection Legislation, we are required to inform you that your details will be retained and held on file for a period of 5 years. This is for administrative purposes only by Marymount University Hospital and Hospice. This information will not be passed on to any other organisation. If, for any reason you no longer wish to consent to us retaining your personal data please send an email to hleahy@marymount.ie.Declaration: All information I have provided is accurate. I have read and agree with the terms and conditions of this application.Course Fee(Required) Price: Course Fee(Required) Price: Course Fee Quantity Price: € 400.00 Quantity Course Fee - Student Quantity Price: € 150.00 Quantity Early Bird fee before 01/02/23.Course Fee(Required) Price: Total: Credit Card:Card Details Cardholder Name CAPTCHA
