Network Application - Emergency Telehealth

Emergency Telehealth Network

Membership Application
Full Name*

First NameLast Name
Email*
example@example.com
ACEM membership number*
What is your primary professional classification?*

FACEMACEM TraineeACEM CertificantACEM DiplomateACEM Advanced DiplomateACEM SIMG
Country/State*

Aotearoa New ZealandAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaOther
City/Town of residence *
Primary place of employment *
Please tell us about any special interests you have that may be relevant to this network.
By submitting I agree to receive news of Emergency Telehealth activities and actively contribute to the Network.
Should be Empty:

Emergency Telehealth Network