ADMISSION FORM

Catholic Hospital,Battor
P.O Box 2
Battor,Via Sogakope
Ghana
Tel:+233558187888 or +233574050308
Email:info@battorcervicalcentre.org

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CERVICAL CANCER PREVENTION AND TRAINING CENTRE

TRAINEE REGISTRATION FORM

Module 1-Basic Module2-Advanced

Surname	Middle nameFirst name
Profession/position
Professional experience in years
Hospital/clinic
Address
Country
Town
Telephone number(s)
Email address
Have you had any previous training in passing a speculum?
Have you had any previous training in cervical screening?
If so how long was the the training for?
Who provided the training?
Module registering for
Proposed period of training(two weeks for each module)	from to
Mode of payment and transaction ID (This information is required for confirmation of payment)
Date