Booking Form

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

Booking Form

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