PASCAR Individual Membership Form

PASCAR Individual Membership Form
Dear Colleague in Cardiology across Africa,

PASCAR is a non-profit organisation that affiliates and works closely with national cardiac societies and organisations across Africa. Official Society affiliation with PASCAR extends to the individual health care practitioners of the affiliated country. However, all health care practitioners in Africa (or from Africa) may indicate their areas of interest and receive communication from and contribute to PASCAR.

Kindly complete the PASCAR Individual Membership Form (free of charge) and we will add you to our database to keep you abreast of news and opportunities in cardiology in Africa.
Type of Membership *You must be deemed worthy of membership by the Governing Council of PASCAR. (*by type of membership)*

Individual Members: This membership is for individuals who have a professional interest in cardiology in Africa and reside in Africa.Associate Members: These are individuals who reside outside of Africa, have a professional interest in cardiology, and wish to contribute to cardiology in Africa.
Title*

DrProfA/ProfOther
Name*
Surname*
Email*
example@example.com
Country*
Mobile Number*
Please enter a valid phone number incl Country code
Institution / Hospital Affiliation *
Please enter the full Institution/ Hospital name
Current Position*
Specialty*

CardiologistCardiology FellowClinical TechnologistElectrophysiologistGeneral PractitionerNursePharmacistPhysicianRadiographerRadiologistResearcherSurgeon - CardiothoracicSurgeon - GeneralSurgeon - VascularOther
Please indicate if you are principally in:*

Private clinical practicePublic clinical practice (government)Private and Public clinical practiceCardiology researchAcademiaOther (please specify)

Rows	Please Select
Cardiac Arrhythmia
Cardiac Imaging
Cardiac Pacing
Cardiac Risk Factors
Cardiac Surgery
Cardiovascular Prevention
Congenital Heart Disease
Heart Failure
Hypertension
Interventional Cardiology
Paediatric Cardiology
Research
Rheumatic Heart Disease

I wish to get actively involved in the following PASCAR Task Force Committees (only select 3):*

Rows	Please Select (Only select 3)
Cardiac Arrhythmia and Pacing (AFHRA)
Cardiac Imaging
Cardiac Surgery
Cardiovascular Disease Prevention
Heart Failure (AFHA)
Hypertension
Structural and Coronary Intervention (PASCI)
Paediatric and Congenital Cardiology (PANPACH)
Research
Rheumatic Heart Disease
Sport Cardiology
None

Maximum selection allowed 3 only
Calculation
I am currently serving on a medical society executive (Name of Society and Position) and/or Leadership at my Institution (Please specify)*
Please list noteworthy cardiology research publications you have been involved in (include URL or link if available)
Form Submission Date

DayMonthYear
Date
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