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* 1. Full name

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* 2. NHS email address

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* 3. Job role

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* 4. Contact number (in case of cancellation/changes)

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* 5. Practice name

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* 6. PCN name

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* 7. Practice Manager name

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* 8. Practice Manager's email address

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* 9. Which area of West Yorkshire do you work in?

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* 10. What course(s) are you applying for? (Maximum of 2 courses per person)

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* 11. You must have permission from your Practice Manager to apply for this course and ensure you can be released from practice to attend

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* 12. We will need to share your details with the training provider.

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* 13. You will automatically be added to our distribution list to receive our fortnightly WY PCWTH Bulletin containing information on our programmes/courses/training/funding etc.. If you wish to opt out, select the following box.

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* 14. Please leave any comments or questions in the textbox below.

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