Membership Form - Pasifika Physiotherapists Association Inc. Society

Membership Form - Pasifika Physiotherapists Association Inc. Society
Membership level*

Member (Pasifika Physiotherapist)Student (Pasifika Physiotherapy Student)Affiliate
Matai/Chief Title
Prefix/Title *
Full Name*

First NameLast Name
Date of Birth *

DayMonthYear
Date
Gender

FemaleMaleNon-binaryPrefer not to sayOther
Phone Number*
Format: (00) 0000-0000.
Phone Number - Home
Format: (00) 0000-0000.
Personal E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Ethnicity*
Current Role / Current Employment
Please select an option below that best describes your current status*

Registered Physiotherapist in Aotearoa NZNon Practicing Physiotherapist in Aotearoa NZStudent Physiotherapist in Aotearoa NZStudent Physiotherapist outside of Aotearoa NZRegistered Physiotherapy outside of Aotearoa NZNon Practicing Physiotherapist outside of Aoteraroa NZOther
Professional area of work*

Public Sector (e.g. Te Whatu Ora Health New Zealand etc.)Private practiceUniversity / polytechnicPrivate hospital or rest homeRetiredOther
Which areas you are interested to help and get involved with?*

Communications/MarketingNetworkingStudent supportAdministrationFundingEvents PlanningOther
Tell us about yourself

To assist us in considering your application, please briefly describe connection to the Pacific (e.g. lineage, area of interest, anything else relevant)
Do you consent to receiving emails from Pasifika Physiotherapy Association?

YesNo
Please verify that you are human*
Should be Empty:

Membership Form - Pasifika Physiotherapists Association Inc. Society

Tell us about yourself