Student Nurses Medical Defence Membership

Date

NI Number

Your title

Your First Name

Your Middle Name

Your Surname

Address

Apartment , Suite, Unity etc.

Town or city

County

Postcode

Personal Email address

Telephone

mobile

Date of birth

Gender

Male Female

Name of School and campus

Year of expected qualification

Current year of study

Are you a PLAB student?*

Yes No

Are you a previous MDS member ?*

Yes No

Previous History

1. Are you aware of any incident or circumstance which could give rise to an event where you may require assistance? *

Yes No

2. Please provide details of any matter involving your name. This includes any pending, unresolved or closed issues. Failure to disclose may invalidate your subscription.

Important Information:

The applicant is responsible for providing accurate information. The signing of the declaration indicates an undertaking by the applicant to keep MDS informed and updated, in writing, of any changes to their personal details and professional circumstances. Failure to notify changes could result in the suspension of the benefits of the membership and/or its termination. MDS would only assist with any matter arising from an incident from the date of commencement. No assistance will be provided in a matter if the member might have been aware of the matter before the commencement of the membership. MDS may approach the previous professional organisation of the applicant for the history of assistance for which your consent will be requested below. When leaving their previous professional organisation, the applicant should notify them of any adverse incident of which the applicant is aware that could become a request for assistance. The applicant should also check with the previous professional organisation whether any closing payment is required to secure 'run-off' cover for any claims which may arise from an incident pre-dating the end of the member's subscription with the previous organisation.

Data Protection:

By completing this application and indicating consent below, the applicant hereby consents that details provided in this application will be retained on our system to be used for administrative, claims processing, research, information and promotional purposes for the purpose of processing the membership application and if membership is granted. Also, the applicant consents MDS to be able to disclose the information to legal or other professional advisors or other medical protection organisations or to the third parties involved in the process of the membership application and in assisting with the services as part of advisory and claims handling process. The MDS Privacy Policy is available on request.

I consent to MDS retaining and processing my information for the purposes of processing my membership application and throughout the duration of my membership. *

Yes No

I consent to MDS or their agents requesting, retaining and processing information regarding past and current matters from other professional protection bodies, insurance companies or employers with whom I have had professional membership agreements to the release of the information. *

Yes No

MDS may wish to provide you with information about other products and services that it may think would be of interest to you.

If you do wish to receive this information, please tick the methods you consent to receipt.

Email Post SMS

Withdrawal of application and cancellation of membership:

Cancellation requests will only be processed when a notice is provided by the member in writing (electronic mail). MDS reserves the right to cancel any membership with immediate effect if there is any breach of the expressed or implied terms and conditions of the membership plan, or when membership has been obtained under false pretences. In such cases there is no automatic right to any advice and representation by MDS.

Important:

The free student membership is valid until such time as you qualify for a licence to practice in the UK and is on a discretionary basis. Declaration: I wish to subscribe to MDS package of services identified in this application. I understand that this will be subject to approval and I consent to MDS or their agents seeking information regarding past and current matters from other professional protection bodies, insurance companies or employers with whom I have had professional membership agreements to the release of the information. I confirm that the information I have given in this application is correct to the best of my knowledge.

I understand that it would be my responsibility to provide accurate information and updating MDS with any relevant changes. Failure to notify may result in the suspension of the benefits and/or the termination of my membership.

I have read the conditions for withdrawal of application and cancellation of membership and agree to accept them. *

Yes No

Student Nurses

Start your career with MDS by your side

Why join MDS as a Student Nurse

Student membership application form

Contact Details

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