Apllicant Form PROGRAMME REGISTRATION FORMPERSONAL INFORMATIONName * Name First Name First Name Last Name Last Name Date of Birth Gender Male Female Email * Phone * Nationality GhanaInternational PROFESSIONAL DETAILS Current Job Title Cadre Theatre In-Charge Perioperative Nurse OR Manager / Coordinator Other (Specify)Years of Experience in Operating Theatre 0–2 years 3–5 years 6–10 years 10+ yearsINSTITUTIONAL INFORMATION Name of Facility * Type of Facility (Select primary facility) Teaching Hospital Regional Hospital District Hospital Private Hospital Mission/CHAG Facility Other (Specify) Region Department INSTITUTIONAL APPLICATION (OPTIONAL)Request bulk invoice Yes NoAre you submitting this application as part of an institutional nomination? Yes No if Yes Number of Nominees NOMINEE 1 arrowup6 Name * Name First Name First Name Last Name Last NameGender Male Female Email * Position Phone * NOMINEE 2 arrowup6 Name * Name First Name First Name Last Name Last NameGender Male Female Email * Position Phone * NOMINEE 3 arrowup6 Name * Name First Name First Name Last Name Last NameGender Male Female Email * Position Phone * SUPPORT & SPONSORSHIPHow will your participation in the programme be funded? Self-Funded Institution-Sponsored OtherIf Institution-Sponsored If Institution-Sponsored Sponsoring Institution Sponsoring Institution Contact Person (Finance/Admin) Contact Person (Finance/Admin) Contact Email/Phone Contact Email/PhoneRequest official invoice Yes NoINSTITUTIONAL APPROVAL (FOR INSTITUTION SPONSORED APPLICANTS)Head of Facility Head of Facility Approving Authority Name Approving Authority Name Position Position Institution Upload Approval Letter (pdf only) Drop a file here or click to upload Choose FileMaximum file size: 8MBRequest For Invoice Yes NoPROGRAMME AVAILABILITY CONFIRMATIONI confirm my availability and commitment to participate in: Pre-Course Facility Diagnostic Activities 2 Weeks Intensive Onsite Training at UGMC 90-Day Facility Improvement ProjectCompletion of the Facility Improvement Project is a requirement for programme certification. Do you commit to completing and submitting the required Facility Improvement Project? Yes NoPREVIOUS TRAINING EXPERIENCE (OPTIONAL)Have you previously attended any Operating Room Management, Perioperative Leadership, Theatre Management, or Surgical Services Training Programme? Yes No If Yes: Please specify programme(s), institution(s), and year(s) attended. DECLARATION & CONSENTHave you attended any OR management or leadership training before? * I confirm that the information provided in this application is accurate and complete. I understand the programme requirements and commit to full participation in all required programme activities I understand that completion of the Facility Improvement Project is required for programme certification. I understand that completion of the Facility Improvement Project is required for programme certification. Submit If you are human, leave this field blank.