£249.00
Remaining Balance – 10th July A&E+GP
Student Name*
First Name
Last Name
Preferred Name
Email*
Contact Number*
Address*
Address Line 1
Address Line 2
City
County
Postcode
Country
Placement Type*
Gender*
Date of Birth*
T-Shirt Size*
Nationality*
Guardian / Emergency Contact Information*
Additional Information
I understand today I am paying the registration fee of £395 for a Premed Project. The remaining total placement fee for the project will be due before the placement begins. By using this form you agree with the storage and handling of your data by this website.
I Agree
Pre Existing Medical Conditions
Email Address *
Dietary Requirements * Please let us know of any dietary requirements you may have
Medical Conditions Let us know if you think we should know about any pre-existing medical conditions. All of our staff will be made aware of them and include any allergies or medication you may be taking.
Emergency Contact Details * Please provide the name, contact numbers, email address and postal address of someone who you would like us to contact in case of an emergency
Anything Else? Is there anything else you think we should be aware of/you would like us to know before your placement?
Please submit your details to notify us that you do not wish to purchase a meal plan for your course, thank you.
Email Address
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