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Goodeve-Docker Prize Nomination Form

The Philip Goodeve-Docker Memorial Prize

For Outstanding achievement as a District Nursing student.

Nominator
Name of University*
Name of nominator (Course leader/Programme leader/registrar)*
First Last
Position held (Job title)*
Nominator's University address*
Address Line 1 Address Line 2 City County Postcode Country
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*
(This will be used only for the purpose of this application)
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 District Nurse 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 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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Goodeve-Docker Prize Nomination Form

The Philip Goodeve-Docker Memorial Prize

Nominator

Nominee student

Criteria

Data protection

Video title

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Goodeve-Docker Prize Nomination Form

The Philip Goodeve-Docker Memorial Prize

Nominator

Nominee student

Criteria

Data protection

Video title