THE UNIVERSITY OF HONG KONG - HKU Nursing



C6/M2/v2/Revised: Nov 6, 2019

THE UNIVERSITY OF HONG KONG

|Carol Yu Centre for Infection |School of Nursing |Infection Control Team |

|Department of Microbiology |Li Ka Shing Faculty of Medicine |Queen Mary Hospital |

Certificate in Infection Control (Full Cert) / Infection Control Course (Individual Module)

Application Form

The personal data provided in this form will be used for processing your application for enrolment on the relevant course, by the administrative and academic departments concerned. This form should be completed and returned together with a cheque, which must be crossed and drawn in favour of “The University of Hong Kong”, to School of Nursing (4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong). Enquiry should be directed to Ms Annie Lau (Tel: 3917-6602 Fax: 2872 6079; email: cichku@ hku.hk)

1. PERSONAL INFORMATION (Please fill in your full name [surname first] in block letters, as in your HKID Card/passport.)

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|Dr/Mr/Mrs/Ms/Miss* | |

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|Name in Chinese characters (if any) | |

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|Address for correspondence: | |

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| |Email address: | |

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|Tel No.: | |

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|Name and address of organization | |

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|3. QUALIFICATIONS | |

4. COURSE ENROLMENT AND COURSE FEE PAYMENT

I wish to enroll:

□ FULL Certificate Course: Module 1 – 6 (Fees: HK$5,400/HK$4,800*/HK$3,000#)

□ Individual Module(s) (Fees: HK$1,000/HK$800*/HK$500# for each module)

|Module 1: Nov 12-13, 2022 (Tentative) |Module 4: Nov 13-14, 2021 (Tentative) |

|Module 2: Apr 17-18, 2021 (Deadline: Apr 2, 2021) |Module 5: Apr 9-10, 2022 (Tentative) |

|Module 3: July 17-18, 2021 (Tentative) |Module 6: July 16-17, 2022 (Tentative) |

Course Fee Special offer:-

* Nursing Alumni, and Honorary Tutors of the School of Nursing (HKU) and Graduate of Certificate in Infection Control

Special Offer: Certificate Course: $4,800; Individual module: $800

# Current part-time students/staff of the School of Nursing (HKU)

Special Offer: Certificate Course: $3,000; Individual module: $500

I would like to enjoy the above special offer:

□ * Alumni (DNur (MNur (FT-BNur (PT-BNur (PT-BNur (EN to RN conversion program)

(Year of Graduation: ________; HKU No.:___________________________)

□ * Graduate of Certificate in Infection Control Course (Year of Graduation: ________; Candidate no.______________)

□ * Honorary Tutor

□ # Current Part-time Student/ Staff (HKU No./ Staff No. _____________; Programme: ___________)

□ Nomination. Payment to be settled by: ____________________ (Name of the Organization)

I would like to carry forward my Individual Module(s) to Full Certificate Course (max. 2 modules):

Candidate No. (e.g.1055): Module & date (e.g. M6 July 2019):

(Successful applicants will have their Individual Module registration fee deducted from Certificate Course enrollment)

^^ Note: The registration fee is non-refundable ^^

The CERTIFICATE will only be granted to candidate registers in the FULL Certificate course, with satisfactory results in the course assessment within 6 years. NO certificate will be given to candidate who attending SIX individual modules separately. For details and request for credit transfer please contact cichku@hku.hk.

Date: ___________________________________________ Signature: ___________________________________________

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For official use only Certificate Course: HK$5,400 / HK$4,800/ HK$3,000 Individual Module(s): HK$1,000 / HK$800/ HK$500

Bank: _______________________________ Cheque No.: _________________________________ Amount: HK$ ____________

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