Student Elective Application Form

Please complete the online form below.

You must upload the completed verification forms when completing the application form. Please ensure you have these to hand as it is not possible to save and return to the application.

*Title

*First Name

*Surname

*Date of Birth

*Address Line 1

Address Line 2

Address Line 3

*Town

County

*Postcode/ZIP

*Country

*Phone

*Email

*Education: Pre-University

*Education: University/Medical School

*Prizes, Awards, Distinctions

*Do you have previous laboratory experience?YesNo

If yes, please provide details

*Have you applied for funds elsewhere?YesNo

If yes, please provide the amount and date you will be informed of the outcome

*Proposed Elective/Project: Institution

*Proposed Elective/Project: Number of complete working weeks

*Proposed Elective/Project: Date of commencement

*Proposed Elective/Project: Date of completion

*Outline of elective work and/or project

Completed verification form from Head of Department where work is to be carried out

Completed verification form from Dean of your current Medical School/Faculty

*Declaration

I understand that my data will be stored by the BDIAP and I may be contacted in the future by the BDIAP on matters relating to this application and/or my membership. This data will be stored in accordance with the BDIAP's data privacy policies and will not be released to third parties. I may request that my data is deleted at any time using the data deletion request form in the data privacy policies section of the website, however, I understand that my data is stored as a contractual necessity of my application/membership of the BDIAP so that if I ask for my data to be deleted this will also mean that I am cancelling my membership and/or withdrawing my application.

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