General Optical Council STUDENT REGISTRATION Application form

Please read the attached guidance notes and complete the form in full. This form is for applicants who wish to register as a student optometrist or student dispensing optician with the (GOC). This form can be typed onto however there are sections that must be completed in writing. These sections will be marked with this symbol. If you are completing this form by hand, complete it with a black pen and in block capitals. For more information about registering as a student with the GOC please visit our website: www.optical.org/en/Registration/Applying_for_registration/Students.cfm If you are not completing an accredited training course as listed on our website please fill out this form but leave section 2 blank. We will contact you to confirm what training you are undertaking. If you require any assistance completing your registration form please contact the registration team at [email protected] or on 020 7580 3898 (option 1). What happens next? Once your form is submitted, approved and payment received you will join the student register. We will confirm this by email along with details of your GOC number and how to access your MyGOC account (the registrant only area of our website).

SR001 08/16 Page 1 Checklist Please complete all sections of the application form and read the guidance notes before completing the form. Have you selected an option from Student Optometrist or Student Dispensing Optician?

Section 1 – Contact details Have you provided your full name, DOB, an email address and selected your registered address? Section 2 – Education establishment Have you entered the start date against the relevant educational establishment? Section 3 – Declarations Have you completed this section? If you ticked yes, have you provided details including relevant documentation? Section 4 – Identification Has the person certifying your identification also signed this application form where indicated? Section 5 – Declaration of information Have you read, signed and dated the application? Section 6 – Payment Have you provided payment details? Guidance notes and monitoring form Have you read the guidance notes before completing the form? An equality, diversity and inclusion monitoring form is enclosed. The information you provide will help us to assess impact and advance the promotion of equality and diversity in the work that we do.

Supporting documents Please ensure you include the following documents with your application. Proof of identity Payment (if paying by cheque) Please do not send originals to the GOC. It is your responsibility to ensure that your registration form arrives at the GOC and that your name is entered on the GOC register.

Page 2 Student registration form

Select the register you are applying for:

Student optometrists Student dispensing opticians

Section 1 – Contact details Your full name, home town and practice address (if provided) will appear on the public register and may be available to third parties. We need your full name, DOB, a physical address, and a contact email address and telephone number so that we can easily contact you about your registration.' Which of the following would you like as your registered address with the GOC to be used for correspondence?

Home Practice

If you do not tick a box we will use your home address as your registered address.

Title (please tick) Mr Mrs Ms Miss

First name(s)

Surname

Date of birth DD// MM YYYY

Email (confirmation of registration will be sent to this email address)

Full home address

Post code

Telephone number

Is this address also a practice address? Yes – if so, this address will appear on the published register. No

Practice where you are undertaking practical experience (if applicable). To be completed in full if different from contact address above. Please attach an extra page for any additional practice addresses.

Name of practice

Full address

Post code

Telephone number

Page 3 Section 2 – Educational establishment where you are undertaking optical training Please indicate the name of your approved educational establishment by noting the start date in format MM/YYYY in the ‘Start Date’ column. The GOC will contact the educational establishment directly to confirm which course you are enrolled in. A list of the GOC accredited and provisionally approved training courses are on the Education section of our website. If you are not completing a training course at one of the educational establishments listed below please fill in the supervision section at the bottom of this page. Student optometrists Start date Anglia Ruskin University MM Y Y Y Y Aston University, Birmingham MM Y Y Y Y Cardiff University MM Y Y Y Y City University, London MM Y Y Y Y Glasgow Caledonian University MM Y Y Y Y Plymouth University MM Y Y Y Y The College of Optometrists MM Y Y Y Y University of Bradford MM Y Y Y Y University of Hertfordshire MM Y Y Y Y University of Manchester MM Y Y Y Y University of Portsmouth MM Y Y Y Y University of Ulster MM Y Y Y Y

Student dispensing opticians Start date Anglia Ruskin University M MYYYY Association of British Dispensing Opticians (ABDO) College M MYYYY ABDO College with Canterbury Christ Church University M MYYYY ABDO Examinations M MYYYY Bradford College M MYYYY City and Islington College M MYYYY City University London M MYYYY Glasgow Caledonian University M MYYYY

Only fill in your supervisor's details if you are not attending one of the educational establishments listed above. Supervisor’s full name

Supervisor’s GOC Number

Supervisor’s practice address (if different from the practice address in section 1): Name of practice

Full address

Post code

Telephone number

Page 4 Section 3 – Fitness to train declarations

Do you wish to make any declarations? Yes Please give full details below Failure to provide full details will delay your application No Please proceed to Section 4 The GOC website provides further guidance in the Registration section under ‘Making declarations’. Criminal matters Please provide details of any conviction in the British Isles or abroad, caution, conditional caution, conditional discharge, absolute discharge or Social Security Administration Act penalty in the British Isles; any agreed offer, penalty payment agreement or absolute discharge order in Scotland; and any investigation or proceedings that could lead to any of the previous outcomes. You must provide details of the date, offence, name of court, any penalty or punishment (including the amount of any fine) and background circumstances. Attach a separate sheet if necessary. You must provide full details of any conviction or caution that is ‘spent’ under the Rehabilitation of Offenders Act 1974, unless it is a ‘protected’ caution or conviction. You do not need to declare any road traffic offences that have been dealt with by way of a fixed penalty but you must provide full details of any road traffic offences that have resulted in a conviction.

Disciplinary matters Please provide details of any determination by the GOC or another body that regulates a health or social care profession either in the UK or abroad, including an NHS Primary Care Organisation or health board; any investigation or proceedings that could lead to a determination by another such regulator; and any breach of the GOC’s Code of Conduct and/or Standards of Practice for individual registrants. You must provide details of the date, incident, name of other regulator, any sanction and background circumstances. Attach a separate sheet if necessary.

Page 5 Physical and mental health Please provide details of any physical or mental health conditions that, in the view of a reasonable person, might currently affect your fitness to train. You must provide details of the date, nature of the condition, diagnosis and any treatment required.

Section 4 – Identification You need to provide one of the following forms of identification with this application: 1. A clear, in colour and certified photocopy of one of the following valid documents: passport, student ID, or UK driver's licence OR 2. A passport sized colour photograph certified with a signature and name of the person signing it on the back. You need to ask a professional person or someone of good standing in your community who has known you for at least two years to certify your chosen form of identification. This can be an optometrist or dispensing optician, solicitor or notary, dentist, teacher or lecturer, or chartered accountant. The person should not be related to you or living at the same address. Instructions for the person certifying your document Once you have the coloured photocopy and original of the applicant's identification document, please complete the following steps on the photocopied document. 1. Write ‘Certified to be a true copy of the original seen by me’ on the document 2. Sign and date 3. Print your name under the signature 4. Adding your occupation, address and telephone number. If the applicant has provided a passport sized photograph instead of a photocopied document please sign and write your name on the back of the photograph. You must also complete this section in writing. I certify that I have known the applicant for at least for at least two years and that the attached identification, which is certified by me is a true likeness.

Name of applicant

Name of person certifying

Position of person certifying

Professional registration number of person certifying (if applicable)

Signed Date

Page 6 Section 5 – Declaration of information - Applicant must sign

I declare that I have read, understood and will comply with the GOC’s Standards for Optical Students. I declare that the information given in this form is true and accurate. I understand which information I have provided (within section 1) will be published on the register and made available to third parties on request and agree to the GOC using the information I have provided to exercise its proper and statutory functions which include updating the register, administering and maintaining registration, processing complaints and compiling statistics or research, in line with the Data Protection Act 1998 (DPA). I understand that my annual retention application will be due by 15 July each year regardless of the date of my registration. I understand that I must notify the GOC immediately if there are any changes to the information provided in this application, including contact details.

Signed Date

Section 6 – Payment

The student registration fee is £25. I have included a cheque payment, made out to ‘GOC’ for the sum of £

I wish to make payment by card over the telephone. Please contact me on this daytime telephone number in order to take my card details.

Telephone no.

If you cannot pay by either of these options, please contact the registration team using the contact details below.

How we use the information supplied in this form The GOC is a Data Controller registered with the Information Commissioner’s Office. We make use of personal data to support our work as the regulator for the optical professions in the UK. We may process your personal data for our statutory purposes which include updating the register, administering and maintaining registration, processing complaints and compiling statistics or research. In line with the DPA, all data provided will be kept secure and not for longer than necessary. This statement confirms our commitment to protect your privacy and to process your personal information in a manner which meets the requirements of the DPA.

If you have any questions Email [email protected] Write to 10 Old Bailey, London EC4M 7NG Telephone +44(0)20 7580 3898, option 1 Mon to Thurs 09.00-17.00, Fri 09.00-16.45 Website www.optical.org

Page 7 Guidance To join the GOC student register you need to do the following five things: 1. Complete all sections of the registration form 2. Sign the declaration 3. Provide a certified photocopy of an identity document or a certified photograph and have the person who is certifying it fill out section 4 of the form 4. Return the completed form and payment to the GOC 5. Pay the student registration fee Section 1 – Contact details Your full name, home town and practice address (if provided) will appear on the public register and may be available to third parties. We need you to provide an email address as this is how you will receive confirmation of your registration and other important communications from us. This is also how you will log into the MyGOC area of the website. On occasion we must send out communication by post. You must select whether your home or practice address will be our registered address for correspondence with you. It should be a reliable address so that important communications can reach you without delay. You must notify us of any changes to your address by using the MyGOC area on our website or in writing to [email protected]. You should also notify us of any change of name as soon as possible. You can do this by enclosing a certified photocopy of the change of name deed or marriage certificate. The name you provide should be the name you are intending to use with your education provider. If it is different from the identification document you provide we may ask for further documentation. If you need more space to complete this section, please continue on a separate sheet of paper. Section 2 – Educational establishment where you are undertaking optical training Please select the relevant education establishment by entering the month and year of when you commenced your optical training. If your educational establishment is not listed please fill in details of your supervisor. If your educational establishment is not listed and you do not have a supervisor please contact [email protected]. Section 3 – Fitness to train declarations In this section you must declare any criminal matters, disciplinary matters and/or physical and mental health conditions. Please ensure that you tick either the YES or NO box to indicate whether you wish to make any declarations about criminal and disciplinary matters and/or physical and mental health. If you tick YES you must provide details in the boxes provided. Our website provides further guidance in the section headed ‘Making declarations’. https://www.optical.org/en/Registration/Making_declarations/index.cfm

SR002 08/16 Page 8 Relevant UK bodies for the purposes of the section ‘Disciplinary matters’ are: • General Optical Council • General Chiropractic Council • • • General Osteopathic Council • Health and Care Professions Council • Pharmaceutical Society of Northern Ireland • Nursing and Midwifery Council • General Pharmaceutical Council • primary care organisations or health boards

How will the information in this section be used? Data provided in this section will not be published on the register, will be kept securely and for no longer than necessary. The registration team may contact you to request further details on your declaration. Failure to respond to an information request will delay your registration application. This information may be passed to our Fitness to Practise team for investigation. False declarations or failure to make relevant declarations may also be passed to our Fitness to Practise team. Section 4 – Identification Please ensure you follow the instructions provided in this section carefully. The person certifying your document or photograph must also complete this section of the form. You should not complete any part of this section. If you do not supply correctly certified documents we will not be able to accept them. If you are having difficulty meeting the requirements of this section please contact [email protected]. Section 5 – Declaration of information Please read the declaration and sign and date the form in the space provided. Section 6 – Payment Cheque payments: Cheques should be in pounds sterling, drawn on a bank based in the UK and made payable to ‘General Optical Council’ or ‘GOC’. Card payments: If you wish to pay by card, please provide a day time contact telephone number in Section 6. Once we are ready to process your application we will contact you by phone to take the payment. Any card payment details received in paper format will not be accepted and will be shredded. Please note that if we are not able to contact you for payment your application may be delayed. If you cannot pay by either of these options, please contact the registration team.

Page 9 GOC Equality, Diversity and Inclusion (EDI) Monitoring Form

This EDI monitoring form can also be completed online here. More about you We are committed to treating everyone fairly, regardless of age, disability, gender reassignment, ethnicity, religion or belief, gender, sexual orientation, marriage and civil partnership, pregnancy and maternity. Completing this form is voluntary however we encourage you to do so as it will help us to measure the impact of our processes, practices and culture. You also have the option to skip questions with ‘prefer not to say’. For more information about why we do this and what we hope to achieve, please see our Approach to EDI monitoring statement: https://www.optical.org/en/news_publications/Publications/equality-and-diversity-reports.cfm. Information provided will be treated in the strictest confidence under the Data Protection Act 1998 and will be only used for monitoring purposes, including publication in our annual monitoring report. No information will be used in any way which allows any individuals to be identified.

Name:

GOC Number (if applicable):

Gender Female Male Prefer not to say

Age 16-24 25-34 35-44 45-54 55-64 65+

Prefer not to say

Sexual orientation Bisexual Heterosexual/Straight Gay/Lesbian/Homosexual

Other Prefer not to say

Disability The Equality Act 2010 defines disability as a physical or mental impairment which has a substantial long- term effect on a person’s ability to carry out normal day to day activities. Do you consider yourself to have a disability? Yes No Prefer not to say

Gender Identity My gender identity is different from the gender I was assigned at birth: Yes No Prefer not to say

Pregnancy/Maternity Are you pregnant, on maternity leave, or returning from maternity leave? Yes No Prefer not to say

Ethnicity White Mixed / multiple ethnic groups English / Welsh / Scottish / Northern Irish / White and Asian / British

British White and Black Caribbean / British Irish White and Black African / British

Gypsy or Irish Traveller Any other mixed / multiple ethnic

Any other white background – please specify: background – please specify:

Asian / Asian British Black / Black British Indian / Indian British African / African British

Pakistani / Pakistani British Caribbean / Caribbean British

Bangladeshi / Bangladeshi British Any other Black background – please specify: Chinese / Chinese British

Any other Asian background – please specify:

Other ethnic group Arab / Arab British

Any other ethnic group – please specify: Prefer not to say

Marital status Civil partnership Divorced/legally dissolved

Married Partner Separated

Single Not stated Prefer not to say

Carer Responsibilities Do you perform the role of a carer? Yes No Prefer not to say

Religion/Belief No religion Buddhist Christian

Hindu Jewish Muslim

Sikh

Any other religion / faith – please specify:

Prefer not to say

Many thanks for completing this confidential monitoring form.