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Full Name
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First
Last
Email Address
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Email Address Confirmation
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For confirmation enter again please
contribute Orientation Caring
Contact Number
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Professional Registration Body
*
GMC
IMC
Professional Registration Number
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Member of Royal College
*
RCPCH
RCPI
RCS
Others (Please specify below)
Member of Royal college selected other
College/University of graduation
*
Year of Graduation
*
Currently working in clinical role
*
Please select
Yes
No
Retired
Other (Please specify below)
Clinical role specify if selected other
Current Hospital of Work
*
City
Current Position
*
ST1-3
ST4-8
Post-CCT Fellow
Irish BST
Irish HST
Trust Junior Clinical Fellow
Trust Senior Clinical Fellow
Specialty Doctor
Clinical/Research Fellow
Associate Specialist
Consultant
Other(please specify below)
Current position if selected other
Any Subspecialty Interest
Interests
*
Research
Mentoring
Leadership/Management
Medical Education/Examination
College work
Other
Current Professional Role
*
ACD/CD/MD
College Tutor
TPD
Head of School
RCPCH Office bearer
BMA Office bearer
Other (please specify below)
Professional role if selected other
How you want to contribute or offer your support through UKIPPO Platform>
Career Advice
Mentoring
Exam prep
Portfolio pathway advice
Leadership Opportunities
GRID application/Support
Other (please specify below)
How to contribute if selected other
Membership Type:
*
Please Select
Full Membership: Full rights and paid yearly
Lifetime Membership
Affiliate Membership: Honorary membership
1- Full membership: £30/Year (to pay yearly and renewed on 1st April). 2- Lifetime Full membership: £300 one off payment required. 3- Affiliate membership: Honorary membership with rights to join activities but no discounts or voting rights will be applicable. Note: Payment will be requested after application approval to activate formal membership.
Equality and Diversity Questionnaire (Optional)
Purpose of Form
This form helps us understand the diversity of our members and ensures we are fulfilling our commitment to equality, diversity, and inclusion. Completion is entirely voluntary. Your responses will be kept confidential and used only for monitoring and statistical purposes. You may select “Prefer not to say” for any question. The information is processed in line with data protection regulations.
1. Age
*
Please select
19 or under
20–29
30–39
40–49
50–59
60–69
70+
Prefer not to say
What is your Age?
2. Gender
*
Please select
Female
Male
Non-binary
Prefer not to say
prefer to self describe- write below
How do you describe your gender?
Gender self specified
3. Disability
*
Please select
Yes
No
Prefer not to say
Do you consider yourself to have a disability, impairment, or health condition that affects your day-to-day activities?
4. Sexual Orientation
Please select
Heterosexual or straight
Gay or lesbian
Bisexual
Prefer not to say
Prefer to self-describe- Use below text box
How do you describe your sexual orientation?
Self Specified sexual orientation
5. Religion or Belief
Please select
No religion
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Any other religion or belief (specify below)
What is your religion or belief?
Any other religion self explained
Caring Responsibility
Please select
None
Primary carer of a child/children (under 18)
Primary carer of disabled child/children
Primary carer of disabled adult (18 and over)
Primary carer of older person
Secondary carer (another person carries out the main caring role)
Prefer not to say
Do you have caring responsibilities for children, adults, or both?
Confidentiality Statement
Confidentiality Statement All information provided is confidential, used only for monitoring purposes, and will not affect your registration. If you have questions about this form or require it in an alternative format, please contact ukippo.info@gmail.com Thank you for helping us promote equality and diversity in our medical society. This template is based on best practices and statutory guidance for equality and diversity monitoring in the UK medical and public sectors.
Email
*
Thank you for your application. The UKIPPO Membership Team will review your submission and contact you by email as soon as possible with the outcome and the relevant bank details for payment. Your formal membership will commence upon receipt of the applicable membership fee.
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