Medical Student Reactivation Form

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.^*

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)^*

Please download and complete the following London Ambulance Service risk assessment checklist form.

Upload your completed risk assessment checklist

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 to all KCL PCP Paramedic mentors. It will be sent to the relevant LAS team in order to facilitate the shift. Please ensure these details are accurate as shifts will not be approved without them.

I consent to all data shared in this registration being shared with the relevant PCP and LAS teams/team members.^*

I consent.
I do not consent.

PCP applications can not be approved without consent to share this data with the aforementioned teams. Please email [email protected] if you have any queries.

I confirm that I have purchased KCL Emergency Medicine Society membership from the KCLSU website^*

Yes

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