NAPICU OT Network Form

SIGN UP TO THE OT NETWORK

Please note the OT Network is only available to members only!
Are you a NAPICU Member?*

No, but I would like to know more about membershipPersonal MemberWard Member

Personal Member Information
Personal Member Name*

PrefixFirst NameLast Name
Personal Member Email*
example@example.com
Job Title*
Example: Assistant OT, Senior OT etc.
Post code*
This is to identify your membership on our system
Have you attended any OT Network meetings in the past?*

No, I am new to the OT NetworkYes I have been to past meetings
*Please note that if your Personal Membership has expired, we will require you to renew this or take out a personal membership before attending any future OT Network meetings
We would greatly appreciate it if you could kindly share some information about the Trust/Ward you work on to help us enhance NAPICU's data for future research. This is entirely voluntary and will not affect your Personal Membership. If you’re happy to provide details, please let us know about:
- Ward/Hospital Name
- Trust Name
- Whether your PICU is mixed or single gender
- The number of beds
- Any other relevant details about your ward
Thank you for supporting NAPICU's ongoing efforts to improve care and research in PICUs!
Please leave your information here:

Ward Member Information
Your Name*

PrefixFirst NameLast Name
Your Email*
example@example.com
Job Title*
Example: Assistant OT, Senior OT etc.
Ward Name*
Hospital Name*
Trust/Organisation Name*
Example: East London NHS Trust or Cygnet Healthcare etc
Please select which is relevant to your ward?*
Have you attended any OT Network meetings in the past?*

No, I am new to the OT NetworkYes I have been to past meetings
*Please note that if your Ward Membership has expired, we will require you to renew this or take out a personal membership before attending any future OT Network meetings

Print Name*
Once completed please return to the administration office – info@napicu.org.uk

NAPICU Administration Office
238 Main Street, Rutherglen, Glasgow, G73 2HP
T: 01355 244 585 E: info@napicu.org.uk
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SIGN UP TO THE OT NETWORK