Your Name

Sex

Name of School/College:

What year will you be in at the time of the event?

Home Address:

Phone:

Your Email

How will you be making the payment?

Please note: Only select others if you have spoken to a member of the Med Success team and discussed your requirements.

How did you hear about Med-Success?

I agree to follow the rules and behave in an appropriate manner. Empower will not accept any liability for any loss, damage or injuries to persons or property who attend this event in any capacity.

Once payment is received, we will contact you to confirm your place on the course.

To make payment via bank transfer please use the details below:

Account name: EMPOWER
Sort code: 60 15 48
Account number: 71268901

Please clearly reference any payments with your full name.

If you are having trouble filling out this form, then please email med-success@empower-youth.org.uk the same details instead. You will need to complete payment before we can confirm a place.

To make a payment via PayPal click the following link: