Paediatric Emergency Medicine Network
Membership Application
Name
*
Please select
Dr
Professor
Associate Professor
Mrs
Mr
Ms
Miss
Mx
Prefer not to say
Prefix
First Name
Last Name
Email
*
Are you an ACEM Member?
*
Yes
No
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ACEM Membership
ACEM membership number
*
What is your primary professional classification?
*
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
Other (Please specify)
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Categories
Please select the category that best describes you
RACP Fellow
RACP Trainee
Nurse or Registered Nurse
Allied Health Professional
Medical Trainee
Medical Doctor
Prevocational Doctor
Other
Are you either of the following? (Select One)
*
Director of Emergency Medicine (DEM)
Director of Emergency Medicine Training (DEMT)
Neither of the above
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Country/State (Select One)
*
Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other
City/Town of residence
*
Where is your primary workplace?
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e.g. Auckland City Hospital
Are you a member of any research networks? (Optional - select all that apply)
ACEM Clinical Trials Network
ACEM Emergency Department Epidemiology Network
Australasian Society for Infectious Diseases Clinical Research Network
Australasian Stroke Trials Network Australia & New Zealand
Australian & New Zealand College of Anaesthetists Clinical Trials Network
Australian & New Zealand Intensive Care Society Clinical Trials Group
Australian Paediatric Research Network
New Zealand Emergency Medicine Network
Paediatric Research in Emergency Departments International Collaborative (PREDICT)
Other, including state-based networks (please specify – can be multiple)
Other Colleges/professional organisations with which you are associated (Optional - select all that apply)
Advanced Paediatric Life Support Australasia (APLSA)
Australasian College of Dermatologists (ACD)
Australasian College of Anaesthetists (ANZCA)
Australian College of Nursing (ACN)
Australian College of Nurse Practitioners (ACNP)
Australian College of Critical Care Nurses (ACCCN)
Australian College of Rural and Remote Medicine (ACRRM)
Australasian College of Sports and Exercise Physicians (ACSEP)
College of Emergency Nursing Australasia (CENA)
College of Intensive Care Medicine (CICM)
College of Nurses Aotearoa (NZ)
Health Informatics Society of Australia (HISA)
International Federation of Emergency Medicine (IFEM)
Nurse Practitioners New Zealand (NPNZ)
Paramedics Australasia (PA)
Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
Royal Australian and New Zealand College of Psychiatrists (RANZCP)
Royal Australian College of General Practitioners (RACGP)
Royal Australasian College of Obstetricians & Gynaecologists (RANZCOG)
Royal Australasian College of Medical Administrators (RACMA)
Royal Australasian College of Physicians (RACP)
Royal Australian and New Zealand College of Psychiatrists (RANZCP)
Royal Australasian College of Surgeons (RACS)
Royal Australasian College of Radiologists (RANZCR)
Royal College of Pathologists of Australia (RCPA)
Royal New Zealand College of General Practitioners (RNZCGP)
I agree to receive PEMN news by email
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No
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What interests you?
Please select all you are interested in:
Education
Research
Advocacy
Governance
Engagement
Please tell us about any special interests you have that may be relevant to this network.
By submitting I agree to receive news of PEMN activities and actively contribute to the Network.
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