GMTS September 2021 Trainee Questionnaire

By sharing the below information, you consent to your information being shared with the University of Birmingham as part of their registration process.

September 2021 Trainees

As part of your registration to the Elizbeth Garrett Anderson Programme, this information is needed by the team at the University of Birmingham to register you as a student in the format below. If you have any queries around how we will use this information collected, please email us at: [email protected]

Title*
First Name*
Middle Name/s
Surname/s*
Preferred Name
Gender*
Date of Birth (dd.mm.yyyy)*
Ethnicity*
Nationality*
Primary Email*
Alternate Email Address (if applicable)
Do you have an nhs.net email address?*
If yes to the above, please give your nhs.net email below.

Please only answer this question if you do have an nhs.net email address already. Skip this question if you answered ‘no’ above.
Primary Phone Number*
Primary Telephone Extension (if applicable)
Alternate Phone Number (if applicable)
Would you consider yourself to have a disability?*
Disability Type
Would you consider yourself to have a learning difficulty?*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
First Placement Address (if known)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If not yet known, please include your region/county.
Specialism*
Role whilst on scheme (if yet known)*
Highest Qualification Held*
Emergency Contact Name*
Emergency Contact Phone Number (please provide multiple if needed)*
Relationship to Emergency Contact*