Application for Genomic Medicine Master’s Funding Thank you for your interest in applying for funding. Please fill the form below carefully, ensuring that you check the information for accuracy before submitting your application for funding. 1. Applicant detailsTitle*MrMrsMissMsDrFirst name*Last name*Email address* Telephone number*2. Current employment detailsDo you currently hold a contract of employment with the NHS in England?*YesNoWhich of these best describes your employment 'sector'?*Please specifyAdministration/ClericalAllied health professionalAmbulance service teamCommissioningDental teamMedical DoctorEducation/teachingGeneral PractitionerHealthcare managementHealthcare ScientistHealth informaticsInformation servicesMedia/Communications/Public RelationsMedical associate professionsMidwiferyNursingOptometristPatient or member of the publicPharmacist or pharmacy teamPsychologistPublic Health PractitionerResearchSocial CareJob title*Please provide details of your current role:*Employer’s full address* Organisation name Street address City County Postcode Is your employer part of a designated Genomic Medicine Centre (GMC) zone? If so, which one?*Please specifyEast of England NHS GMCGreater Manchester NHS GMCNorth East and North Cumbria NHS GMCNorth Thames NHS GMCNorth West Coast NHS GMCOxford NHS GMCSouth London NHS GMCSouth West NHS GMCWessex NHS GMCWest Midlands NHS GMCWest of England NHS GMCWest London NHS GMCYorkshire and the Humber NHS GMCDon't knowIf you're unsure, please refer to this map of GMC zones.Name of senior line manager*Senior manager is defined as someone in a position of responsibility who can make decisions on absence from work and the appropriateness of undertaking the selected training programme.Line manager contact telephone number:*Line manager email address* Please provide the email of your Senior Line Manager who has the authority to approve your application and authorise any agreed study leave. Once you have submitted this form, they will receive an email containing details of your application and will be required to approve it by following the instructions provided in the email. If they do not receive an email regarding your application please ask them to search their junk email folder.3. Programme of study detailsWhat is your planned course of study?*MScPGDipPGCertWhat is your preferred mode of study?*Full TimePart TimeHas your university application been successful?*YesIt is in progressI have not started my applicationWhat is your preferred start date?*Autumn 2018Spring 2019Autumn 20194. Course ProviderWhich university are you applying to?*We only allow funding applications to a single university. If your university application is unsuccessful, you will need to reapply for funding by contacting firstname.lastname@example.orgUniversity of BirminghamQMULUniversity of ManchesterImperial CollegeSt GeorgesCambridge5. Additional informationPlease provide any other relevant information that may assist in making a decision about this application for funding:6. Previous funding applicationsThis section will help the Genomics Education Programme identify accurate allocation of funds. If any of this information is found to be false, misleading or incomplete, the Genomics Education Programme may decline your application.Have you previously applied for Genomics Education Programme funding?*YesNoWas your application approved for funding?*YesNoWhat is/was the funded course of study?MScPGDipPGCertCPD Module(s)Have you completed or are currently undertaking the course for which funding was secured?*YesNoTermsBy clicking 'submit' you agree that your application is accurate and complete to the best of your knowledge and also that you consent to the details of your application being shared with your line manager, the University you are applying to and any other professional organisation needed to assess and verify your application.Do you agree to have your application shared with your selected course provider and Genomic Medicine Centre?*YesNoDo you agree to receive information regarding further opportunities from the Genomics Education Programme?*YesNoCaptchaNameThis field is for validation purposes and should be left unchanged.