University Hospitals of Leicester NHS Trust Libraries & information services: Online registration form

Title (e.g. Mr, Mrs, Dr): *

First name *

Last name: *

Job title: *

Employer/commissioning group: *

Hospital department & address: *

Work email:

Work telephone:

Area Code Phone Number

Bleep:

Home address: *

Home email:

Home telephone:

Area Code Phone Number

Mobile telephone:

Data protection statement

The information that you provide to us via this form is used to offer you library and knowledge services during your employment, studies or placement with the NHS or other healthcare or academic organisation. This form is operated by JotForm, a US based company and the information is then entered onto our library management system. Your information will remain on the JotForm server after you submit the form and on the library management system for the duration of your library membership. The library system uses a server in the UK operated by IS Oxford. A paper or online version of this form may additionally be stored to assist the work of library staff while you are a member of the UHL Libraries & Information Services. If you do not wish to use this online form, you can come into one of the libraries and fill in a paper form.

We will try to keep your details as accurate as possible. Every year we will ask you to update your details. If we do not hear from you after several attempts to contact you, your details will be deleted from our system. You have the right, at any time, to see what information we hold about you, have any information corrected, request that we delete any information we hold about you. However please be aware that if you ask us to delete some or all of your information, it may affect what services we are able to offer you.

If you have any concerns regarding how we use this information, or you have any questions, please do not submit this form but rather contact one of the library team.

We never pass your details on to other organisations unless required to by law.

Declaration *

I have read the library regulations (in the attachment above) and data protection statement (above) and agree to abide by the library regulations and consent to the data I am providing being used and stored in these ways. I also understand my rights in relation to the data you hold about me. (To be a member of UHL Libraries & Information Services, you must agree to this declaration. If you do not agree, or want further information, please do not submit this form).

Please indicate whether we could send you occasional emails with news from the library service and the resources we provide.

I am happy to receive these occasional emails (optional)

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	Copyright © University Hospitals of Leicester NHS Trust, 2014 UHL Libraries & Information Services is part of the Department of Clinical Education.