Geriatric Emergency Medicine Network
Membership Application
Name
*
Prefix
First Name
Last Name
Email
*
Are you an ACEM member or trainee?
*
Yes
No
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ACEM Membership
ACEM Membership Number
*
What is your primary professional classification?
*
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
What is your primary professional classification?
*
Geriatrian
Nurse or Registered Nurse
Allied Health Professional
Medical Trainee
Medical Doctor
Prevocational Doctor
Other (Please specify)
Are you any of the following?
*
Director of Emergency Medicine (DEM)
Director of Emergency Medicine Training (DEMT)
None of the above
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Where are you located?
Location
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
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?
*
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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 you have that may be relevant to this network.
*
What are your clinical interests outside of Geriatric EM (toxicology, ultrasound, research)
*
0/100
What would you like membership of the GEM Section to provide you?
*
0/100
How could you contribute to the GEM Section?
*
0/100
I agree to receive GEMS news by email
*
Yes
No
By submitting I agree to receive news of GEMN activities and actively contribute to the Network.
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