Medical Student Reactivation Form RM_Stats First Name * Last Name * KCL Email * Non-KCL email * Date of birth * Mobile Number * Please provide a mobile number which we can use to contact you in case of emergency. Term Time Address * KCL students intercalating at another university or external students intercalating at KCL are not able to join the KCL PCP due to insurance and indemnity reasons. I confirm that I am NOT intercalating externally or an external student. * Yes Please select your year of study. * Select an option MBBS 1 EMDP1a EMDP1b GPEP 1 MBBS 2 MBBS 3 Intercalating MBBS 4 MBBS 5 Please download and complete the following London Ambulance Service indemnity form. Please complete all 3 pages where indicated. Under 'Emergency Contact' please provide BOTH A NAME & PHONE NUMBER. Leave the 'call sign' and 'authorising manager' section blank. Upload your completed Indemnity Form (all pages of our new updated form) * We also require the details of your next of kin. This is so we can contact them in the case of an emergency or if you are involved in a road traffic collision whilst in the ambulance. It is also a requirement of the LAS for you to go on shift with them. Name of Next of Kin * Relationship to Next of Kin * What is your relationship to your next of kin? Next of Kin Mobile Number * Please provide a mobile number for your next of kin which we can use to contact them in case of emergency. Your Indemnity form including NOK details will be accessible by all KCL PCP Paramedic mentors. It will be sent to the relevant LAS team in order to facilitate the shift. This year the PCP team is carrying out a study to better understand how the PCP influences medical students' clinical skills and experience, via a pre and post programme short questionnaire. Please read the information sheet and upload a completed copy of the following consent form indicating your preference regarding participation. PCP Study Consent Form Upload * I confirm that I have purchased KCL Emergency Medicine Society membership from the KCLSU website * Yes JavaScript is turned off in your browser. The form may not work properly.
