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Please fill out the form in as much, or as little, detail as you like. Boxes marked in bold must be completed in order for us to register you for the alumni service.

GMC no: (if applicable)

Surname:

Surname when at SGHMS/SGUL:

Forename(s):

Title:

Honours:

Date of Birth:

Marital Status:

Address (including postcode):

Home Tel:

Daytime Tel:

E-Mail Address:

Education:

Entry Year at SGHMS/SGUL:

Leaving Year:

Course :

Employed
Not Currently Employed
Retired

Date of Retirement if applicable:

Income pa: (Optional response)

Personal Interests:

If you reside with another graduate of SGHMS/SGUL or know someone else with an interest in St George's who would like to receive information in their own right please give details:

Name:

Address:

Other suggestions for Alumni activity:

We would like to know what kind of potential services from the Alumni Office would interest you. Please tick boxes accordingly where 5 indicates a strong interest and 1 indicates no interest.

	A Magazine
	Info for Alumni on the Web
	Events
	Conferences and CPD
	Sports Reunions
	Discount deals
	Merchandise
	Library use
	Sports facility use
	Recruitment & mentoring

Placements at St George's and Partner Institutions (if applicable):

Pre-clinical School if not St George's:

Other qualifications at SGHMS:

Qualifications gained elsewhere with dates:

Positions of responsibility/Membership of clubs at SGHMS/SGUL:

Employment:

Present Post (If applicable)

Other posts held with dates:

Professional Memberships:

Directorships:

Any attendance at, or organisation of, reunions since leaving (formal or informal):

IMPORTANT DATA PROTECTION DECLARATION

Data protection laws have recently changed in accordance with EC legislation.

All information on this form will remain confidential to St George's Alumni Association in accordance with the Data Protection Act 1988. The data will only be available to the office and to agents contracted by them for specific membership related purposes such as the circulation of the magazine and other school publications, notification of events and information on alumni benefits and special offers. Data might also be used at some future time to give you information about developments at St George's and the opportunity to offer financial support.

Under the terms of the data protection act we are obliged to obtain your agreement to the use of your data for these purposes.

I agree to the use of my data for all the above purposes.