Title:

First name * (required)

Surname * (required)

Email: * (required)

Institution / workplace: * (required)

---- Alexandra Hospital, Redditch Coventry & Warwickshire Partnership NHS Trust George Eliot Hospital NHS Trust (GEH) Primary Care South Warwickshire NHS Foundation Trust (SWFT) University Hospitals Coventry and Warwickshire NHS Trust (UHCW) Warwick Medical School (WMS) Other – please specify below

If you selected ‘other’, please specify your institution / workplace:

Job title: * (required)

MBChB role: * (required)

What are your aims in attending the conference? Students: This information will be used in allocating places if demand exceeds available places . * (required)

Students only: Current Phase:

---- Phase 1 Phase 2 Phase 3 (Year 3) Phase 3 (Year 4)

Please let us know if you have any special requirements, including dietary requirements, that we would need to take into account in the arrangement and delivery of this event:

Privacy notice

This form will be used to manage attendance at the MBChB Education Conference. Your attendance at the event and information you provide will be recorded and associated with your name but no other personally identifiable data will be stored and the data will not be used for any purpose other than as a record of the event.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.