Advancing Women in Emergency Network
Membership Application
Name
*
Title
First Name
Last Name
Email
*
Are you an ACEM member or trainee?
Yes
No
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ACEM Membership
ACEM membership number
*
Membership Category
*
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
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Categories
Please select the category that best describes you
Nurse or Registered Nurse
Allied Health Professional
Medical Trainee
Medical Doctor
Prevocational Doctor
Other
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Where are you located?
Country/State
*
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?
*
Please list your places(s) of work
*
Please tell us about your leadership experience (hospital/college/university/other)
*
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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 or experience you have that may be relevant to this Network (clinical/academic/other)
*
What do you hope this Section might achieve?
Would you be interested in taking on a mentor position?
By submitting I agree to receive news of AWE activities and actively contribute to the Network.
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