Membership self-declaration form

Please use this form to request a change in your membership subscription of the College.

The College’s less than full time (LTFT) discount is valid for one year of membership and a new self-declaration form requesting this discount is required each year.

If you are on maternity or extended paternity leave or adoption leave, the College provides one year of membership without a fee. The Membership Engagement team will confirm which year of membership your submission is applied to when they review your request.

If you are on, or have been on long-term sick leave for six months or more the College, and it's Faculties, can offer you a Supported Subscription fee. The Membership Engagement team will confirm which year of membership your submission is applied to when they review your request. If, unfortunately, your sick leave spans longer than one membership year you can submit a further request for this financial support.

Membership record details

Title

Forename(s)

Surname

College Reference Number (CRN)

Email address

GMC Number

Postcode

Please complete only the sections which are relevant to you.

Less than full time discount

My working hours are 79% or less than:

I work less than eight programmed activities (including wider professional activities) per week

Yes

No

I work less than 0.80 whole time equivalent

Yes

No

Maternity and extended paternity leave requests

I will be going on parental leave from:

Until approximately:

My parental leave has been extended from:

Until approximately:

Long term sick leave discount

I am on long term sick leave from work for six months or longer

Yes

No

I have been, or will be, on long term sick leave from work for six months or longer

Yes

No

Signature

Please sign above using your mouse or finger (if using a touchscreen device)

Date

I can confirm that the details provided at time of application are correct

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

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