HANDS ON | India's First AI Simulation Institute

1

Applicant Category

I am applying as *

Medical Student (MBBS / BDS) Nursing Student (GNM / B.Sc. / M.Sc. Nursing) Paramedic / Allied Health Professional Resident Doctor / Postgraduate (MD / MS / DNB) Practicing Doctor / Specialist / Consultant

2

Personal Details

First Name *

Last Name *

Date of Birth *

Gender *

WhatsApp Number

Must be 10 digits starting with 6-9

Mobile Number *

Must be 10 digits starting with 6-9

Number Verified Successfully

Email Address *

Residential Address *

3

Academic & Professional Details

Degree / Qualification *

Year / Semester *

College / Hospital / Institution *

University / Affiliated To

Roll No. / Registration No. *

MCI / NMC / State Council Reg. No.

4

Skills Lab Enrollment Preferences

Skill Modules You Wish to Enroll In *

Basic Life Support (BLS) & CPR Advanced Cardiac Life Support (ACLS) Airway Management & Intubation IV Cannulation & Venepuncture Suturing & Wound Management Obstetric & Neonatal Simulation Laparoscopy & Surgical Simulation Trauma & Emergency Simulation (ATLS) Ultrasound / FAST Examination

Other Skill Module (If Any)

Preferred Session Type *

Weekday Weekend Either

Preferred Time Slot

Previous Hands-on Simulation Training?

Yes No

How Did You Hear About Us?

5

Documents & Verification

Recent Passport-Size Photo *

Click to upload photo

Format: JPG, PNG. Max size: 2MB.

(For offline print form: paste photo here 3.5 × 4.5 cm)

Documents Checklist (To be submitted) *

College / Institution ID Card (Copy) Enrolment / Registration Certificate Aadhar Card (Copy) MCI / NMC Registration (For Practitioners) NOC from HOD / Department (If required)

6

Emergency Contact

Contact Person Name *

Relationship *

Contact Number *

Must be 10 digits starting with 6-9

7

Declaration & Signature

I hereby declare that all information provided in this application form is true and correct to the best of my knowledge. I agree to abide by the rules, regulations, and code of conduct of the Hands-on Medical Simulation Centre. I understand that any false information may result in the cancellation of my enrollment without refund.

Applicant Signature *

Digital Signature / Sign Here Sign Here (Print)

Place & Date *

For Student Applicants — Countersignature of HOD / Guide

Signature with Official Stamp

Name: _________________________ Designation: _________________________

For Office Use Only

Application Received By

Date Received

Enrollment ID Assigned

Fee Receipt No.

Enrollment Status

Approved Pending Documents Rejected

Official Remarks

Application Form

Hands-on Medical Simulation Centre