Pre-Hospital and Retrieval Medicine Network
Membership Application
Full Name
*
Title
First Name
Last Name
Email
*
example@example.com
Are you an ACEM member or trainee?
*
Yes
No
Back
Next
ACEM Membership
ACEM Membership Number
*
Membership Category
*
ACEM Advanced Diplomate
ACEM Associate (Foundation EM Associate)
ACEM Associate (Advanced)
ACEM Associate (Intermediate)
ACEM Certificant
ACEM Diplomate
ACEM Fellow – FACEM
ACEM International Affiliate Member
ACEM PHRM Associate
ACEM Retired Fellow
ACEM Trainee – FACEM
ACEM Trainee – Associateship
Back
Next
Categories
Please select the category that best describes you
*
Nurse or Registered Nurse
Allied Health Professional
Medical Trainee
Medical Doctor
Prevocational Doctor
Other
Back
Next
Where are you located?
Country/State
*
Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other
City/Town of residence
*
Are you currently employed in a PHRM Service?
*
Yes
No
What is the service name?
*
What is your FTE at the service?
*
Back
Next
What interests you?
Please select all you are interested in:
Education
Research
Advocacy
Governance
Engagement
Are you undertaking research related to PHRM?
*
Yes
No
What is your area of research?
*
Please outline any special interests you have that may be relevant to the PHRM Network.
*
0/100
I agree to receive PHRM Network news by email
*
Yes
No
By submitting, I agree to receive news of network activities and actively contribute to the Network.
Submit
Should be Empty: