Student elective application

To let us know you are going on elective, whether in the UK or abroad, please complete the form below to allow us to update your membership status.

Personal details

First name Last name Male Female Home address Postcode Is your term address the same as your home address? Yes No Term address Term postcode Email Date of birth University Year of graduation MDDUS student membership number Medical Dental

Elective details

Date first elective commences Date first elective ends Country of proposed elective Professor/Consultant you are working for Name of hospital Hospital address Hospital postcode Date second elective commences Date second elective ends Country of proposed elective Professor/Consultant you are working for Name of hospital Hospital address Hospital postcode

Please note that MDDUS does not provide protection in respect of electives performed in Australia due to the legislative requirements in that jurisdiction.

Important: It is the responsibility of any individual to ensure that the cover provided by MDDUS meets the requirements of the host country and establishment where the elective placement is being undertaken. MDDUS cannot accept any responsibility for any failing in this respect by any person undertaking an elective.

Please check the box to confirm that you understand and agree to the above statements in order to proceed.

Student elective application

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