EM Clinical Trials Network - Online Membership Form

PrEMS Membership Application Form
Full Name *

First Name Last Name
Email *
example@example.com
ACEM Membership Number
What is your Primary Professional Classification? *

FACEM ACEM Trainee ACEM Certificant ACEM Diplomate Medical Officer/Intern Nursing Staff Other Specialty Consultant Other Specialty Trainee Allied Health Worker Medical Administration Paramedic Research Staff
Are you any of the following? *

Director of Emergency Medicine (DEM) Director of Emergency Medicine Training (DEMT) None of the above
Country/State *
City/Town of Residence *

Street Address

Street Address Line 2
What is your Primary Place of Employment? *
(e.g. Auckland City Hospital)
Are you employed in a private ED? *

Yes No
Hospital Name *
Are you undertaking research related to private emergency medicine? *

Yes No
Please tell us about any special interests you have that may be relevant to this Section (clinical/research/other) *
I agree to receive PrEMS news by email *

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PrEMS Membership Application Form