Medical University of Lublin

Registration for vaccinations against COVID-19 for students/PhD students

Registration Form

Before completing the form, please read the DECLARATION OF CONSENT & INFORMATION CLAUSE

Student ID number*

5 digits e.g. 12345)

First name*

Surname*

Date of birth*

DD-MM-YYYY

Passport Number or PESEL*

Country issuing passport*

Gender*

Student email address*

make sure you entered your university email: .....@student.umlub.pl

Phone number*

please include country code before the full phone number e.g. Poland: (+48) 123456789

Faculty*

Program*

Year of study*

Permanent address in Poland

street*

no. of house/flat*

postcode*

city*

MANDATORY FIELD - please attach a scan or a good quality photo of a personally signed declaration of consent to the processing of personal data

  * - fields required

Calendar

July 2021