UCT FHS REGISTRATION FORM (Intro to Laboratory Animal Science)

Course Name: Introduction to Laboratory Animal Science

Course Date

Title (e.g.: Dr / Mr / Mrs / Miss)

Name*

First NamesSurname

Full Name to appear on certificate*

Student Number (if previously registered with UCT)

ID Number / Passport Number*

Date of Birth (DD/MM/YYYY)

Nationality*

Highest Educational Qualification*

HPCSA / SANC Number

Occupation

Company

Supervisor (if a degree student)

Title of Research

Animal Species Studied

Years of experience working with animals*

Years of experience working with rats and mice*

Will you personally be working hands-on with animals?*

NoYes

The following information is required for UCT reporting purposes:

Gender

Race

Disability (please select)

NoYes

If yes, please specify

How did you hear about this course?

Postal Address

Postal Code

Country

Mobile Number

Email Address (The link to access your digital certificate will be emailed to this address)*

example@example.com

Do you have any special dietary requirements? NB: Only religious requirements and allergies can be catered for.

Allergies

If you have a food allergy, please specify here:

Do you have any other special requirements that we should be aware of?

YesNo

If you have any special requirements, please provide details:

May we add your name to our mailing list to receive notification of future courses?

YesNo

Please upload a copy of your ID *

Please upload a letter from your supervisor in support of your application and confirming your work with animals*

Who is paying for you to attend this course?*

My employer/company is payingI am paying for myself

The link for payment/invoicing will be emailed to you upon acceptance of your application.

1. We will acknowledge receipt of your registration form. If there are no available spaces, you will be notified.

2. Closing date for registrations is dependent on the particulars of each course. You may not cancel your registration after registrations have closed.

3. Fees are due immediately upon registration, unless otherwise arranged with the Continuing Education Unit.

4. We must be informed of cancellations in writing at least two weeks before the start of the course or the full fee will be charged.

5. Where cancellations are received after the course material has been sent to the delegate, the full course fee will be charged.

6. UCT reserves the right to take any legal proceedings to recover the full fees payable, and to recover the costs in connection with such recovery.

7. Certificates are issued in digital format only. The link to access this document will be sent to the email address provided on this registration form. No certificate will be issued until full payment of the course fee has been received.

8. Certificates will not be issued to any student who is not in financial good standing with UCT.

9. UCT reserves the right to cancel any registration or revoke certification should the student have any tertiary education disciplinary measures against their name.

10. UCT reserves the right to cancel the course if insufficient registrations are received, in which case, the course fee will be refunded in full if already paid.

I have read and accept these terms and conditions.

Signature*

Date (DD/MM/YYYY)*

REGISTRATION FORM

Personal Details

Contact Details

Miscellaneous

Payment Information

Terms & Conditions