Name :		Grade :
Speciality :
Hospital :		GMC number :
Address :
		NTN number :

Phone number:		CCT date:
Email address:	A value is required.Invalid format.

LEAVE REQUESTED
Course name:
Start date:		Number of days:
End date:
Course location:(City)		(Country):
Describe how course fits into your PDP		Other comments

EXPENSES
Transport	Claiming Yes No	Estimated cost:
Course/ Conference fee	Claiming Yes No	Estimated cost:
Subsistence/ Accom	Claiming Yes No	Estimated cost:
Are you receiving grant from any other source? Yes No

DECLARATIONS
Tutor's email (CT1-3):		I confim the Tutor has given permission
Trainer's email:	A value is required.Invalid format.	Please make a selection. I confim my Trainer has given permission
Rotamaster's email:	A value is required.Invalid format.	Please make a selection. I confim Rotamaster has been informed
Doctor providing cover:
FALSE DECLARATIONS ARE CONSIDERED BREACHES OF TRUST AND GMC REGULATIONS, AND WILL BE DEALT WITH ACCORDINGLY Click to view Study Leave Guidelines		I confirm that the facts on this form are true Please make a selection.
A copy of this Study Leave application will be sent to your email address

SCHC Sexual Conditions Health Center