Registration Form for CPC Certificate Course

Registration form for the 8-month online certificate course on children's palliative care

Name(Required)
Email(Required)
Address(Required)
Please provide your delivery address to receive a copy of our book. (South African residents only)
Please record the name of the institution where you work and / or volunteer
Institution status(Required)
Please describe the status of the institution named above.

Sex
This information is required for the purposes of reporting to our funders.
Race
This information is required for the purposes of reporting to our funders.
Do you have a disability?
This information is required for the purposes of reporting to our funders.
PatchSA Membership(Required)
Please indicate if you are a paying member of PatchSA and entitled to a 10% discount on the course
If you are a PatchSA member, please provide your membership number below
Consent(Required)

Payment

Once we have received your registration, you will be invoiced accordingly.