Medical Students Application Form

Please complete our application form below. All fields are mandatory as this information is required for insurance/indemnity reasons.
Copies of documents may be uploaded as images (e.g. taken by camera). All applications are reviewed by the PCP team and will be processed within 10 working days.

Username^*

Password^*

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Enter password again^*

First Name^*

Last Name^*

Gender^*

Male
Female

Mobile Number^*

This is used to contact you in case of emergency.

KCL Email Address^*

You must use your KCL email address (e.g. [email protected])

Term Time Address^*

Intercalating students are currently not able to join the KCL PCP due to insurance and indemnity reasons. I confirm that I am NOT an intercalating student.^*

Please select your year of study.^*

Please select your year of study. Unfortunately, do not currently allow intercalating students to join the PCP due to insurance/indemnity reasons.

Why do you want to take part in the Prehospital Care Programme? (approx 150 words)^*

Talk about any relevant experiences you have. (approx 150 words)^*

What do you feel you could bring to the KCL PCP? (150-200 words)^*

What do you feel you could gain from the KCL PCP? (150-200 words)^*

Talk about your personal view on the value of prehospital care and working in the prehospital environment. (150-200 words)^*

Upload a copy of your KCL ID card^*

Upload a copy of MDU/MPS Card/Certificate^*

Please upload either your MDU/MPS card or certificate of insurance.

Please download and complete the following London Ambulance Service indemnity form. This form must be countersigned by a witness and must be taken with you on every ambulance shift.

Upload your completed LA123 Indemnity 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 of Next of Kin to you^*

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.

I confirm that I have watched the LAS observer shift training video^*

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

KCL PREHOSPITAL CARE PROGRAMME APPLICATION FORM

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