www.drmikekingtrust.co.uk
info@drmikekingtrust.co.uk

Parent, Carer and Student Consent Form

Medical Pathways Programme · a free programme for sixth formers in and around Portsmouth who want to study medicine

DRAFT for review by the Trust’s safeguarding lead and partner schools before use.

About the programme

Activities may include talks and panels with doctors and medical students, medical-school and careers information, clinical and scientific workshops, ethics and interview (MMI) practice, UCAT and application guidance, webinars, and the chance to write for the Future Doctors Journal and enter the Year 12 poster competition. Activities take place at partner schools and colleges, universities, healthcare and community venues, or online.

Taking part does not depend on agreeing to photographs or publication. You can say yes to some things and no to others, and change your mind at any time.

1. About the student

First name

Surname

School or college

Year group

Student username, if you have one (e.g. amber-falcon-42)

Date of birth (to check whether parent/carer consent is needed)

2. Permissions

Please tick Yes or No for each line. The student and the parent or carer both answer. A permission is used only if everyone answers Yes.

Permission	Student	Parent/carer
Taking part. Take part in the programme’s in-person activities: talks, workshops, mock interviews and work experience arranged by the Trust.	Yes No	Yes No
Online sessions. Take part in online activities and webinars. Some sessions may be recorded for the Trust’s own use; students are always told first.	Yes No	Yes No
Photos at events. Be photographed or filmed at Trust events.	Yes No	Yes No
Photos used publicly. Photographs or video that show the student may be used on the Trust’s website, social media, newsletters and annual report. Full names are never used in captions.	Yes No	Yes No
Publishing work. Articles and posters the student writes may be published on the Trust’s website with their first initial and surname (for example “A. Khan”). Their school is not shown.	Yes No	Yes No
Evaluation. The Trust may ask the student about their experience and progress, and report the answers only as anonymous totals.	Yes No	Yes No
Personal statement for interview practice. The student may upload their UCAS personal statement for a practice interview (MMI Station 6). Only Trust admins and the examiner for that student can read it, and it is deleted automatically within 7 days of the event. This is optional.	Yes No	Yes No

3. Student

Signature

Date

4. Parent or carer (not needed if the student is 18 or over)

I have parental responsibility for the student named above and have read this form.

Full name

Relationship to the student

Signature

Date

Your information

The Trust keeps this form as a record of permission. Published work shows only the student’s first initial and surname, never their school. You can change any answer at any time by emailing info@drmikekingtrust.co.uk, or from the student’s account page. Full details: www.drmikekingtrust.co.uk/privacy-notice.

Return this form to the sixth-form office at your school or college. Or give permission online instead: the student registers at www.drmikekingtrust.co.uk/students and enters your email address.