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Dora Roylance Prize Nomination Form

The Dora Roylance Prize for Student Health Visitors

who have completed the Specialist Community Public Health Nursing (SCPHN) Health Visitor programme.

Nominator
Name of University*
Name of nominator (Course leader/Programme leader/registrar)*
First Last
Position held (Job title)*
Nominator's University address*
Street Address Address Line 2 City County Postcode
Nominator's phone (Work)*
Nominator's email*
Enter Email Confirm Email
Nominee student
Name of student*
First Last
Address for correspondence to student*
A postal address is required for all recipients of any QNI funds.

Street Address Address Line 2 City County Postcode
Email*
Enter Email Confirm Email
Date of Graduation Ceremony:*
DD slash MM slash YYYY
In which academic year was the course completed?*
DD slash MM slash YYYY
Criteria
The following section will help the QNI understand how universities are selecting the most outstanding Health Visiting student of the year.
Why are you selecting this student for the prize?*
(e.g. highest mark in practice, highest mark overall during the course)
Data protection
Your privacy is important to us, and we will NOT pass your details to any third party. The Queen's Nursing Institute will use the information provided on the application form to process the award only. We will also use the information to communicate with you on issues which we feel may be of interest to you. By providing us with your information, you consent to us using it for the purposes outlined above.
Consent*
- I give consent for the QNI to keep my details and I have authorisation to share the nominated student’s details with the QNI.
Signature
Date
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Dora Roylance Prize Nomination Form

The Dora Roylance Prize for Student Health Visitors

Nominator

Nominee student

Criteria

Data protection

Video title

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Dora Roylance Prize Nomination Form

The Dora Roylance Prize for Student Health Visitors

Nominator

Nominee student

Criteria

Data protection

Video title