New Student Portal Registration Form

Welcome to the Mentorverse. We are so excited to start this journey with you. Please complete the following form to register for Mentorverse Programmes. Following this you will receive an invite to join our community on Circle. Here you will find everything that you need to join our programmes. You'll start on the Bronze Pathway, which gives you an Insight into Medicine through free conferences, virtual societies, fundraising events and virtual work experience. By completing this form, you are agreeing to Medic Mentor's Privacy Policy: https://medicmentor.org/wp-content/uploads/2023/10/Medic-Mentor-Student-Privacy-and-Information-Sharing-Policy.pdf

Students Email Address

Please make sure that this is typed out in lower case

Student's First Name

Student's Surname

Student Contact Number

School Year Group

Home Postcode

Please provide your home postcode

School

Add

Are you a home student or international student?

Career Choice

Parent/Guardian's Title

Parent/Guardian's First Name

Parent/Guardian's Surname

Parent/Guardian's Email Address

Parent/Guardian's Contact Number

Ethnicity

A1 White British
A2 White Irish
A3 Any other White background
B1 Mixed White/Black Caribbean
B2 Mixed White/Black African
B3 Mixed White/Asian
B4 Any other Mixed background
(C) Asian or Asian British
C1 Indian
C2 Pakistani
C3 Bangladeshi
C4 Any other Asian background
(D) Black or Black British
D1 Caribbean
D2 African
D3 Any other Black background
(E) Chinese or other Ethnic group
E1 Chinese
E2 Any other
I do not wish to disclose

Teacher's Title

Teacher First Name

Teacher Surname

Teacher's Email

Teacher Role

Do you believe you meet Widening Access Criteria?

Yes
No
Not Sure

Student Code of Conduct

Please read the Student Code of Conduct tab of the following webpage: https://medicmentor.org/student-code-of-conduct/ I understand and agree to abide by Medic Mentor’s Student Code of Conduct . I understand and agree, that if I violate Medic Mentor’s Student Code of Conduct, I will be subject to the procedure for dealing with alleged breaches of the Student Code of Conduct, as detailed below.

Parent Consent

Please read all tabs on the following webpage: https://medicmentor.org/student-code-of-conduct/ I understand and agree that myself and my child must abide by Medic Mentor’s Student Code of Conduct. I understand and agree, that if I or my child breach Medic Mentor’s Student Code of Conduct, that we will be subject to the procedure for dealing with alleged breaches of the Student Code of Conduct.

Declaration

I declare that this information I have provided is true and complete. I understand that any wilful mis-statement or omission may result in the cancellation of my place on this programme.

Joining Instructions

Send me emails about the event and important information about the application process and resources to support me

Do not submit passwords through this form. Report malicious form

Alert