Apply for Affiliate Membership Part 1 - Personal details Title - Select -DrMrsMissMsMrProfessorOther Initials Title - other Forename(s) Surname Date of birth (DD/MM/YYYY) Address Address 1 Address 2 City/Town County Postcode Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Telephone no Email Part 2 - Reason for seeking membership of the College I have an interest in: Anaesthesia Critical care Pain management Other Interests - other Please select the statements which are relevant to you: I am not a registered medical practitioner but work closely with anaesthetists as an Anaesthesia Associate (AA) I am not a medical practitioner but hold a higher degree and/or can demonstrate achievement at a higher degree level I hold a postgraduate Diploma in Anaesthesia Practice (as issued by the Universities of Hull, Hertfordshire, Birmingham or Edinburgh) I work in veterinary practice and hold one of the following; Certificate in Veterinary Anaesthesia of the RCVS, Diploma in Veterinary Anaesthesia of the RCVS, other postgraduate qualification in veterinary anaesthesia approved by the RCVS and the RCA Please provide a copy of your RCVS or RCA examination certificate One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Curriculum vitae Please upload your curriculum vitae One file only.10 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Payment method My preferred payment is - Select -Direct debitDebit/credit cardOther Once we have verified your application form, our Membership team will be in touch to arrange payment by your preferred method. Payment method - other Equality, diversity and inclusion We have a strong commitment to equality, diversity and inclusion within the College, and these principles are embedded into our values and the way we work. It is for this reason that we are working hard to create and foster the proper representation of ethnic minority, gender and other groups that share protected characteristics in the work of the College and wider specialty. In order to achieve this we are conducting wide-ranging projects to obtain the necessary data to underpin a strategic, supportive and open approach to EDI. To help us do this, we encourage you to complete the following questionnaire on ethnicity, diversity and inclusion as this data will help us: develop a more detailed picture of our membership profile so we can consider and address areas of under-representation better understand the needs of our Fellows, Members and stakeholders inform strategic planning and policy reform to improve equality, diversity and representation across our work assess the impact of our initiatives and; promote, develop and foster positive relations between different groups. In line with the Data Protection Act 2018 (C.12), the College will always keep your information safe and stored appropriately. Please see our Privacy Policy for further details. You can request for your data to be deleted if you change your mind. The College is determined to create a more inclusive environment at all levels where differences are valued and respected. PLEASE NOTE: If you have provided the below information previously and your details have not changed, you are not required to complete this form. Ethnic groups are based on the Census 2021 categories Ethnicity - Select -Asian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - OtherBlack/Black British - AfricanBlack/Black British - CaribbeanBlack/Black British - OtherMixed - White & Black AfricanMixed - White & Black CaribbeanMixed - White & AsianMixed - OtherWhite - BritishWhite - IrishWhite - ScottishWhite - EnglishWhite - Northern IrishWhite - WelshWhite - GypsyWhite - Irish TravellerWhite - RomaWhite - OtherOther ethnic group - ArabAny other ethnic groupPrefer not to say What is your sex? -Select-FemaleMalePrefer not to say If you are considering how to answer, use the sex recorded on your birth certificate or Gender Recognition Certificate. Which best describes your gender? - Select -FemaleMaleNon-BinaryPrefer not to sayPrefer to Self-Describe Gender self-describe Do you identify as Trans? -Select-YesNoPrefer not to say Your religion or belief - Select -BuddhistChristianHinduJewishMuslimSikhPrefer not to sayNo religion of beliefAny other religion or belief Sexual Orientation - Select -BisexualGay manGay womanHeterosexualOtherPrefer not to sayPrefer to self-describe Sexual Orientation self-describe Do you consider yourself to have a disability according to the terms given in the Equality Act 2010? Yes No Prefer not to say The Equality Act 2010 protects people with disabilities. The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (ie has lasted or is expected to last at least 12 months) and adverse effect on the person's ability to carry out normal day to day activities. Do you have carer responsibilities? Yes No Prefer not to say Is English your first language? Yes No Prefer not to say I am interested in the Member Engagement Panel*: Yes No *The Membership Engagement Panel is an online virtual panel of membership that receive surveys and opportunities to share feedback to the College and help us shape future strategy and work. Confirmation Data Protection Statement The Royal College of Anaesthetists (RCoA) is fully committed to the principles of data protection, as set out in the Data Protection Act 2018 (C.12). The RCoA relies on legitimate interests as the lawful basis for processing of personal data. We process and maintain personal data about you so that we can manage your membership, provide you with appropriate products and services and share information with you about RCoA activities. We will only use your information for the purposes as described and will not pass on your details to other third parties unless you have given us consent to do so. We use appropriate organisational and technical measures to ensure that your data are secure and protected from loss, misuse and unauthorised access or alteration. You have the right to ask for a copy of the information we hold about you and to have any inaccuracies in your information corrected. If you have any questions about data protection or require further information, please email dpo@rcoa.ac.uk I have read and understand the College's data protection statement I confirm I wish to apply for Affiliate membership of the Royal College of Anaesthetists CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
