Microcredential Application Form

Microcredential Application Form
Please email education.sct@gmail.com with any questions related to this form.
Personal Details
Name*

First NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Work Email*
Personal Email
Gender
Ethnicity
We collect ethnicity and gender data to report on diversity and the representativeness of our membership. Feel free to select multiple options, or "prefer not to answer" if this is the case.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please note this will only be used in the case of a medical or mental health event.
Do you have any medical conditions that the SCT need to be aware of?
This is to help us provide appropriate information & training, or put plans in place to support your learning.
Employment Details
Job Title*
Name of Department
Hospital*
District*
Country*
Start Date of Current Position*

DayMonthYear
Date
Weekly Hours*
Are you a member of PiCSA?

YesNo
Course Selection & Payment
Please select the relevant option;*

Cardiac Physiology Technician Advance Practice ModulesBasic ECG Interpretation Course - $250
Years of Experience
Professional Qualification

CPMOther
What year was this qualification achieved?
Which module are you applying for?

Ambulatory Monitoring Analysis - $500
Please upload your CV, including all procedures you currently perform;

Cancelof
Please describe your role, and why ECG interpretation is required;
Payment Options;*

Invoice to applicantInvoice to employer
Manager's Name

First NameLast Name
Manager's Email
If you select 'invoice to employer', the invoice will be sent to the details you have entered as the Charge Physiologist in the employment information section. Please ensure this has been discussed prior to submission.
Course Supervision
Your supervisor is the clinical educator that you will discuss your training with on a regular basis, and who will be responsible for the final approval of your course documents. This may need discussion with your charge physiologist/team leader/manager.
Supervisor's Name*

First NameLast Name
Supervisor's Title
Supervisor's Email*
Current APC and CPRB Registration?*

YesNo
If your supervisor is not the Charge Physiologist at your hospital, please provide their details below;
Charge Physiologist's Name

First NameLast Name
Charge Physiologist's Title
Charge Physiologist's Email
Will your training be supported by another hospital?

YesNo
Secondary Supervisor's Name

First NameLast Name
Secondary Supervisor's Email
example@example.com
Declaration
- I declare that the statements I have made are accurate.
- I declare to be governed by the rules & regulations of the society and advance the objects of the Society.
- I agree to inform the society immediately of any change in circumstances which may affect my right to continue as a member of the society.
- I consent to be a Member of the Society.
- I agree to promptly advise the Society of any change to my name and/or contact details.
- I agree to my supervisor and charge physiologist/team leader/manager receiving information from SCT regarding my course progress and results.
- I have read and understand the fee refund policy.
Signature

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Microcredential Application Form

Personal Details

Employment Details

Course Selection & Payment

Course Supervision

Declaration