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Student Summer School 2015Application Form
Completed forms should be returned by email to; [email protected]
Completed forms sent after 6th August 2015 will not be considered
The theme this year is: ‘Healthy Communities: a 360° approach’
The benefits of health and social care practitioners working in partnership with local communities.
1. ABOUT YOU
Title: Surname:
Forenames Gender Female / Male
Date of Birth (DD/MM/YY) Is the address below your term-time address? Yes / No
Contact Details
Postal Code: Country:
Tel: Fax:
Email:
Any special dietary requirements/ food/skin allergies? If yes please specify
Please tell us about any other specific health/wellbeing requirements e.g. religious, access, hearing?
2. YOUR COURSE/UNIVERSITY
College of Medicine, Guys Hospital, Ground Floor, West Wing, Great Maze Pond, London, SE1 9RTThe College of Medicine is a Registered Charity in England and Wales No. 1145676Registered Office: Park Gate, 161-163 Preston Road, Hove, BN1 6AG. Registered in England and Wales No. 07081491E: [email protected] T: 0844 873 7388 web: www.collegeofmedicine.org.uk : @CollegeofMed : CollegeofMedicine
University:
Course:
Current year of study
Start Date: Graduation Date:
Student ID no.:
3. WHY WOULD YOU LIKE TO ATTEND THE SUMMER SCHOOL? Please tell us briefly why you would like to attend the ‘Healthy
communities: a 360° approach’ Summer School. (maximum 150 words)
4. PARTICIPATING IN THE SUMMER SCHOOL WORKSHOPS
The second day of the Summer School involves participatory/experiential workshops – could you please confirm whether that you are willing to fully participate in the activities.
Yes
No
Please tick this box to confirm that you acknowledge that you accept responsibility for your own health and wellbeing at the event
Yes, I confirm
5. REFEREES
Please provide the contact details of one referee (which may be an academic tutor).
In the event that we need to contact your referee, we will not do so without contacting your first.
Referee
Name
Position & Organisation
Relationship with applicant
Address
Email Telephone
5. POSTER COMPETITION
Please note it is not compulsory to enter our poster competition – it will not influence your application to attend the summer school. However if you wish to present a poster at our summer school please complete the title and abstract (max 250 word abstract) sections below. Applications to the poster competition must be submitted on this form by the same deadline (also 10th July 2015). We are not able to accept poster submissions via email or other means.
Poster applications must be related to this year’s theme of “Healthy Communities: a 360° approach’. Research, audit, service evaluation, case reports and literature reviews will all be considered, but they must be your own work or work you have contributed to (there may be other authors). If you have any queries about the work you wish to submit please email [email protected]. There are generous cash prizes for this poster competition.
Successful applicants to the poster competition will be notified by 2nd August 2015 and we will send you further details of the requirements for your poster then.
Would you like to submit a poster to our poster competition? Yes
No
If yes, the title of my poster is:
If yes, the abstract for my poster is (max 250 words):
NEXT STEPS
1. Please email your completed registration form to [email protected]
2. Forms received after 5pm 10th July will not be considered.
3. You should receive an acknowledgement email within 24hrs of receipt of your form. If you do not, please email [email protected].
4. Please note that the College endeavours to allocate as many places as possible to all students applying. However, as part of the purpose of the event it to have as many disciplines represented as possible it may be that where a discipline is under-represented applicants from that discipline will be prioritised.
5. Successful applicants will be notified by 2nd August at the latest. You will also receive an invoice/payment details for your delegate place.
6. Once your payment has been received, your place at the Summer School will be confirmed. Please note that until receipt of payment your place is not guaranteed.
7. The College’s standard payment terms are 14 days from the date stated on the invoice.
8. If your payment has not been received by the due date and you have not contacted us, your place will be automatically offered to a student on our waiting list and we reserve the right to charge you a £50.00 cancellation fee to cover our administration costs. We may also inform your referees.
DATA PROTECTION
Personal information contained on this form shall be used solely for administration by the College of Medicine. We may also use this
information for the sole purpose of sending you information about College of Medicine events and services. If you do not wish to
receive this information please tick the box.
The College of Medicine will not sell your data to third parties.
The College of Medicine confirms that the information on this form is held subject to regulation of the Data Protection Act 1998.