I wish to apply to become a medical student member of MPS. I understand that my membership is subject to the terms and conditions of the MPS Memorandum and Articles of Association.
1. Your Details
2. Your Course
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3. Your contact details
4. Previous History
Do any of the following apply to you (now or in the past):
Have you ever had professional indemnity/insurance:
- Criminal convictions or police cautions
- Disciplinary or personal conduct issues
- Refused, cancelled (including a decline to renew) or made void
- Offered with non-standard terms or conditions imposed such as an increased subscription
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If the answer is no, please type no
Your Personal Information
When interacting with MPS, you may choose to give MPS information about your criminal convictions and offences (including alleged offences), your health, race, ethnic origin, sex life, sexual orientation and trade union membership (“Special Category Data”). This happens where that information is relevant to your membership or the actual or potential provision of advice, assistance or indemnity. We may also receive Special Category Data about you from others in connection with membership or advice, assistance or indemnity (e.g. from a complainant, claimant, witness, expert, court or regulator).
To find out more about how we collect, use and handle your data including Special Category Data, please see our Privacy Statement.
You may withdraw consent to such processing by contacting MPS, but if you do so we will no longer be able to provide you with membership and its benefits.
By submitting this form you agree and confirm that:
(i) You wish to apply for membership of MPS subject to the Memorandum and Articles of Association
(ii) You understand that any failure to disclose full and accurate details may delay your application and/or if you are accepted into membership could result in the suspension and/or withdrawal of membership benefits and/or the cancellation and/or termination of membership
(iii) You understand that membership is not conferred automatically and is subject to approval by MPS
(iv) You will inform us if your contact details or relevant personal circumstances change
(v) We may seek information from other professional defence organisations, insurance companies, employers, and/or other third parties in respect of membership and that they may release to us such information
(vi) For the purposes of New Zealand law and the New Zealand Privacy Act 2020 and any other applicable data protection laws, we may obtain, process, retain and transfer your personal data as set out in the Privacy Notice
You may cancel your membership at the end of any subscription period by giving us prior notice, or during a subscription period upon two months’ notice.
Your application will be administered by MAS on behalf of Medical Protection