Please complete ALL relevant blank fields clearly and in full. If fields marked with an *asterisk are blank these must be completed.
RCOG College number / Status / Member electSECTION 1 / PERSONAL DETAILS
*Surname
*Forename/s
Title:(Dr, Miss, Mr) / Qualifications
*Date of Birth / Not for publication.
(DD/MM/YYYY)
SECTION 2 / PROFESSIONAL AND EMPLOYMENT DETAILS*GMC/IMC number – Limited or Full registration / Please complete if you are resident in the UK
I am unemployed / since:
EMPLOYMENT INFORMATION
Current Substantive Post (eg: Consultant, SpR, Staff)
Date appointed:
SECTION 3 / ADDRESS AND CORRESPONDENCE DETAILS
Employing Trust (if applicable) - please write name of Trust
EMPLOYMENT ADDRESS DETAILS
Hospital/Unit/Surgery
*Postcode / Please ensure that this postcode field is completed
Work Telephone
(Direct Line only)
Work e-mail
RESIDENTIAL/HOME ADDRESS DETAILS
*Postcode / Please ensure that this postcode field is completed
Telephone
(landline)
Mobile
Personal e-mail
SECTION 4 / MAILING PREFERENCES
*Preferred address for correspondence / Home / or / Work
*Preferred e-mail for correspondence / Home / or / Work
Register of Fellows and Members
The RCOG’s Register contains your core membership details e.g. Name, Status - whether Fellow or Member - year of Fellowship or Membership , Registration Number, Country and Qualifications / The above postal correspondence address will be listed in the online and published Register of Fellows and Members. Please tick this box to the right if you do not wish any address data to appear in the Register
The above email correspondence address will be listed in the online and published Register of Fellows and Members. Please tick this box to the right if you do not wish your email address data to appear in the Register /
SECTION 6 / ETHNICITY AND DIVERSITY MONITORING
The College is committed to treating everyone fairly and meeting our legal responsibilities under the Equality Act 2010 and related legislation. One of the ways we do this is by asking members and trainees to provide information about their ethnicity, disability, gender, religion and beliefs.We understand that some of the protected characteristics can be sensitive so providing this information is optional.If you choose to provide it to us, we will ensure that when processing and storing your information we’ll consider the privacy and compliance implications of the Data Protection Act 1998.
I WOULD DESCRIBE MY ETHNIC ORIGIN AS:Asian/Asian British
□ Bangladeshi
□British
□ Indian
□Pakistani
□Sri Lankan
□Any other Asian background
Black/African/Caribbean/Black British
□African
□ British
□Caribbean
□ Any other Black background
Other ethnic group
□Arab
□Chinese
□Dutch
□Egyptian
□French / Mixed/multiple ethnic groups
□ British
□White and Asian
□ White and Black African
□White & Black Caribbean
□ Any other mixed background
White (UK & Ireland)
□ British
□ Irish
□ English
□Scottish
□Welsh
□Northern Irish
□German
□Italian
□Iranian
□Japanese
□Jewish
□Korean
□ Malaysian
□ Nigerian
□Portuguese
□Romanian
□Russian / □Singaporean
□Sudanese
Other ..…………………………………..
□I do not wish to disclose this
I WOULD DESCRIBE MY NATIONALITY ORIGIN AS:
□British
□Irish
□English
□Scottish
□Welsh
□Northern Irish
□American
□Australian
□Bangladeshi
□Barbadian
□Canadian
□Chinese
□Dutch / □Egyptian
□German
□Ghanaian
□Greek
□Hong Konger
□Indian
□Iraqi
□Jordanian
□Libyan
□Malaysian
□Maltese
□Mauritian
□Myanmar
□New Zealander / □Nigerian
□Pakistani
□Polish
□Romanian
□Singaporean
□South African
□Sri Lankan
□Sudanese
□Syrian
□Trinidadian
□Zimbabwean
□Other ..……………………………..
□I do not wish to disclose this
PLEASE INDICATE YOUR RELIGION OR BELIEF:
□ Atheism
□Buddhism
□Christianity
□Islam / □Jainism
□Sikhism
□Hinduism
□Judaism / □No Religion
□Other ……………………………..…
□I do not wish to disclose this
Do you consider yourself to have a disability, long-term illness or health condition? / □ Yes □I do not wish to disclose this
□No
SECTION 7 / PRIVACY STATEMENT
PRIVACY STATEMENT
In accordance with the Data Protection Act 1998, the College will process personal data, by any means (including electronically), for the purpose of providing benefits and services to its members and to carry out its day to day business. Some of this information will be made available to RCOG Fellows and Members in a secure area of the College's website, including in countries where individual rights are not protected by data protection law.
The College may also confirm your qualifications and membership to bona fide third parties including governmental and medical regulatory bodies, educational institutions, members of the public and prospective employers, including those in countries where individual rights are not protected by data protection law. No further information will be released without your prior consent.
All Fellows and Members have a right to access their personal data which the College holds and also the right to correct these data. To obtain a copy of such data (or any part of it), in the first instance, please contact the Membership Team at . The College is entitled to make a charge for the provision of such data. If you have any comments on, or if you object to the terms of this Statement, please contact the Member Records Manager.
From time to time, with your permission, the College may release names and address details of its members to interested third parties for marketing and survey purposes. All organisations and persons are carefully vetted by the College before this information is released. Any such data comprising sensitive details (including data relating to age, health or ethnicity) will not be disclosed without prior consent from you.
If you doNOT want your contact details passed to organisations for marketing and survey purposes, please tick this box.
I hereby declare that I have read and understood the Royal College of Obstetricians and Gynaecologists privacy statement and understand how my personal information will be handled and processed by them.
Signature / Date