RCOG VOLUNTEER LAY SPOKESPERSONFOR FERTILITY
APPLICATION FORM
Role Title / RCOG VolunteerLay Spokesperson on the subject of fertilityIf you would like to be a lay spokesperson for the RCOG on the area of fertility, please express your interest through a short personal statement below.You should outline your particular experience relating to fertility and why you would like to become a spokesperson for the College. Please also answer the other questions below.
Please email your completed application form to: midnight on Sunday 7th June 2015.
Following this we will invite suitable applicants to have a short chat with representatives from the College on Skype to discuss the role further.
If you would like to discuss this role further before expressing your interest, please get in touch by email or telephone.
Telephone: 0207 772 6443
Matthew Miles
Patient Experience and Public Engagement Facilitator
Royal College of Obstetricians and Gynaecologists
27 Sussex Place
Regents Park
London
NW1 4RG
Why would you be suitable to the role of voluntary lay spokesperson for fertility?
(Please outline your own experience in relation to fertility)
Your contact details
Name:
Address:
Home telephone number:
Mobile telephone number:
Email address:
Other information
It would be good to know from you the following information to help us process your application.
Please delete as appropriate in response to the statements below:
I have been a media spokesperson before yes no
I have done other work with the media yes no
I have had media training yes no
If you’ve answered yes to any of the above, please give more details:
------
------
Please let us know which of the following media activity you are content to undertake. Please circle yes or no as appropriate:
Pre-recorded TV interviews yes no
Live TV interviews yes no
Pre-recorded radio interviews yes no
Live radio interviews yes no
Interviews for a newspaper, magazine
or other publication yes no
Interviews for online and social media outlets yes no
Write articles, blogs or quotes etc. for
a media outlet yes no
If you have a preference for when you undertake interviews, or have other commitments that prevent you from being a spokesperson at certain times of the day, or on certain days or dates, please specify which times, days and dates are best for you to undertake media activity on. If you have no particular preference, please say “no preference”:
------
If you have any potential conflict of interest that might impact on your being a spokesperson for the Royal College, please let us know when submitting your application:
------