Student Opt-In to the Temporary Nursing Register

NHS COVID-19 DEPLOYMENT

Student Number *

Forename *

Surname *

National Insurance Number *

Email Address *

Telephone Number (please prefix with 0) *

Course Title (please select from the drop-down list) *

Cohort (please select from the drop-down list) *

Year of study (please select) *

Are you in the 2nd 6 months of your final year of study? (Please select) *

Current Home Placement Location (please select from the drop-down list) * Current Home Placement Location (please select from the drop-down list)

If currently Employed/Working, which organisation? (Please select from the drop-down list) If currently Employed/Working, which organisation? (Please select from the drop-down list)

If you have a job in place for September – which organisation? (Please select from the drop-down list) If you have a job in place for September – which organisation? (Please select from the drop-down list)

Preferred place of work (please select from the drop-down list) * Preferred place of work (please select from the drop-down list)

Postcode of current residence *

Are you opting-in to be added to the temporary nursing register? (Please select from the drop-down list) *

Notes and recommendations

Please confirm you are consenting to the data that you have provided in the above form being shared with Health Education England and NHS Trusts across the United Kingdom.

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