School Of Clinical Dentistry.

Dental Hygiene And Dental Therapy.Application Form For Entry In April 2018.

Please refer to the Application Guide before completing.

A: Personal details

Surname: Title:

Forenames: Previous surname:

Date of birth: Age on 9 April 2018:

Gender: Male Female Have you applied before? Yes No If yes, for what year?

Country of birth: Nationality:

Do you have ‘settled status’ in the UK? Yes No No. of years in UK:

To be eligible for any NHS financial support you must meet certain immigration and residence criteria. For up to date information and full details on eligibility visit the website: www.nhsbsa.nhs.uk/students

B: Contact details

Address:

County: Postcode:

Tel: Mobile:

Email:Please notify us of any change of address as soon as possible, to ensure that any correspondence reaches you.

C: Criminal convictions

Do you have any criminal convictions? Yes No This includes any ongoing investigations, spent convictions, cautions, verbal cautions and bind-over orders.

D: Employment history

Please give details of your most recent employment in date order.

Name and address of employer Nature of workFromMM/YYYY

ToMM/YYYY FT/PT

E: Education

Please give details of the most recent secondary school/college/university you have attended in date order.

Name and address of school, college or universityFromMM/YYYY

ToMM/YYYY FT/PT

For Office Use Only

Date Received

App No.

F: Qualifications completed

Please enter details of all examinations or assessments for which results are known including those failed in date order. Please enclose transcripts for BTECs, Access to HE courses, degrees or overseas qualifications.

Awarding body

DateMM/YYYY

Subject, unit, module or component

Qualification or level

Result, grade or band

Awarding body

DateMM/YYYY

Subject, unit, module or component

Qualification or level

Result, grade or band

G: Qualifications to be completed or results pending

Please enter details of all examinations or assessments for which results are pending. Please remember to contact us when you receive your results for these qualifications.

Awarding body

DateMM/YYYY

Subject, unit, module or component

Qualification or level

Result, grade or band

Awarding body

DateMM/YYYY

Subject, unit, module or component

Qualification or level

Result, grade or band

H: English language

Please state your first language:

Please list any English language qualifications you have (GCSE, IELTS etc).

Qualification Awarding body Overall grade/score Date of award (MM/YYYY)

If you haven’t got an English language qualification but you’re going to take one in the near future, tell us about it below.

Qualification Awarding body Expected date of test (MM/YYYY)

I: Supporting statements

Please supply answers for each of the four questions in the spaces below in support of your application. Each section should be between 150 and 200 words long. Refer to the Application Guide before completing.

i. Why do you want to be a dental hygienist/therapist? Why do you think you will make a good dental hygienist/therapist? Include details of any relevant work experience in your answer.

ii. Why is good communication important in dentistry? Give an example of where you have used your communication skills to deal with a difficult situation.

I: Supporting statements continued

iii. What does professionalism mean to you? Give an example of where you have acted with integrity.

iv. Why is teamwork important to dentistry? Give an example of where you have demonstrated effective team working.

J: Widening Participation Scheme

Have you participated in a Widening Participation Scheme (eg ADOPT)? Yes No Go to section K

If yes, please give details: Name of scheme From (MM/YYYY) To (MM/YYYY)

K: Reference

Please include a reference (on headed paper) with your application. It should be signed and then sealed (with another signature across seal) by your referee. Your referee should be a recent employer/tutor who can comment on your character and suitability for the programme and profession. In the space below give details of your referee.

Name: Title:

Address:

County: Postcode:

Tel: Email:

How long have you known the referee: In what capacity:

L: Disability details

If you have a disability, it’s important to let us know so we can make sure you get the support you need. This information is not used by academic staff when they consider your application.

Please tick the most appropriate box for you.

I do not have a disability and I am not aware of any additional support requirements (000)

Blind or partially sighted (020)

Deaf or hearing impairment (030)

Wheelchair user or mobility difficulties (040)

Personal care support needed (050)

Mental health difficulties (060)

An unseen disability (eg diabetes, epilepsy, asthma) (070)

Multiple disabilities (080)

Autistic spectrum disorder (eg Asperger’s syndrome) (100)

A specific learning difficulty (eg dyslexia) (110)

A disability not listed here (960)

Information withheld (970)

If you have a disability, do you have any related support needs? Yes No If yes, please give details here:

L: Checklist

Please use the list below to check your application is complete and ready to be submitted.

Yes Referred to the Application Guide before completing the application form

Yes All sections of the application form completed

Yes NA Transcript enclosed for BTECs, Access to HE courses, degrees or international qualifications

Yes Reference enclosed (signed and sealed with signature across seal)

Yes Declaration signed

Yes Equal opportunities form completed

Yes NA Stamped addressed envelope enclosed (to receive confirmation of receipt of application)

Yes Correct postage used (according to size and weight)

M: Declaration

All decisions by the University are taken in good faith on the basis of the information you provide in your application form. If we discover that you have made a false statement, or have failed to provide significant or relevant information, we are entitled to withdraw or amend our offer, according to the circumstances. You may even be required to withdraw from the course if you have already started it. In accordance with data protection regulations, the information contained in this application will be used for the purpose of processing your application and, if you are admitted, will form the basis of your University student record.

I certify that the information I have given is complete and accurate.

Signed: Date:

Deadline for receipt of completed application forms (including reference):

Friday 29 September 2017.If your application form is received after this date it will not be processed.

Please return completed applications to:

Dental Hygiene and Dental Therapy OfficeSchool of Clinical DentistryUniversity of SheffieldClaremont CrescentSheffieldS10 2TA

School Of Clinical Dentistry.

Dental Hygiene And Dental Therapy.Equal Opportunities Form.

This information is treated confidentially. It is not passed on to the academic staff considering your application. We use it to keep track of the number of students joining us from each ethnic group. This helps us promote equality and diversity.

For details of our equal opportunities policy, visit our website: www.sheffield.ac.uk

Equal opportunities

Please tick the term you feel describes your ethnic origin and return this form along with your application. If none of the terms seem appropriate, tick box 80. If you want to withhold this information, tick box 98.

White (10)

Black or Black British – Caribbean (21)

Black or Black British – African (22)

Black – other background (29)

Asian or Asian British – Indian (31)

Asian or Asian British – Pakistani (32)

Asian or Asian British – Bangladeshi (33)

Asian or Asian British – Chinese (34)

Asian – other background (39)

Mixed – White and Black Caribbean (41)

Mixed – White and Black African (42)

Mixed – White and Asian (43)

Mixed – other background (49)

Other ethnic background (80)

Information withheld (98)