NAPICU Associate Member Application Form

Associate Member Application Form

Apply to join the NAPICU Associate Committee as an Affiliate or Member. For healthcare professionals in psychiatry, mental health, or PICU units.
Associate Committee Application

Thank you for your interest in joining the NAPICU Associate Committee.

The Associate Committee exists to support and enhance the work of NAPICU by involving professionals with experience in psychiatry, mental health services, and PICU/mental health units. Members of the Associate Committee contribute to projects, events, and initiatives that advance high-quality care and practice.

You may apply for one of two roles:
• Associate Affiliate
• Associate Member

All applications will be reviewed by the Committee and are subject to approval and, where required, voting. Both roles include a 1-year probation period during which your engagement and contributions will be reviewed. Active participation is expected, including involvement in meetings, events, or project work.
Personal Details
Full Name

First NameLast Name
Phone Number
Email Address
example@example.com
Job Title
Organisation / Trust
Primary Address

Street Address

Street Address Line 2

City

Postal / Zip CodeCountry

Role Selection
Were you invited by an Executive Committee member to join the Associates Committee?
Please name the NAPICU Executive Committee Member who invited you to join
Are you or your ward a current NAPICU member?
Is your membership a Ward or Personal membership?
Please provide your Ward name that has a membership
Which role are you applying for?
Associate Member status requires current NAPICU membership.

New Applicant for the Associates Committee

Provide your background and experience below
Outline your experience working in PICU or mental health services (if applicable).
Number of years of relevant experience in psychiatry/mental health services.
Areas of special interest within mental health/psychiatry.
Previous involvement in committees, leadership roles, or professional groups (please describe).
Please explain why you would be a valuable addition to the Associate Committee and what you can contribute.
Describe any contributions you have made to psychiatry or mental health services (e.g. service development, quality improvement, advocacy).
Have you contributed to any of the following?
Please provide details of the contributions selected above (including titles, dates, and your role where relevant).
Upload supporting documents (e.g. papers, articles, publications, certificates).

Upload a File

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References
Reference Name
Reference Job Title
Reference Organisation
Reference Email Address
example@example.com
Upload references or testimonials from colleagues/managers (optional but encouraged).

Upload a File

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Current Executive Committee Member

Please fill out the information below
Number of years as a NAPICU Executive Committee Member
What factors have led to your decision to step down from the Executive Committee and transition into the Associate Committee?
Why do you feel it is beneficial for both yourself and NAPICU for you to remain involved through the Associate Committee rather than stepping away completely?
Please identify the activity you anticipate undertaking during the next 12 months to fulfil your Associate Committee commitment.

Commitment & Responsibilities
1. I understand that I am expected to complete at least one contribution per year, such as attending a meeting, attending a symposium, supporting a training event, or contributing to publications or guidance.
2. I understand that this role includes a 1-year probation period, during which my engagement and contributions will be reviewed.
3. I understand that failure to meet participation expectations may result in removal from the Associate Committee.
4. I understand that joining the Associate Committee does not guarantee progression to the Executive Committee, and that any progression is subject to availability and voting.
I understand and agree to all of the above commitments & responsibilities
Final Declaration
I confirm that, to the best of my knowledge, all information provided in this application is accurate and complete.
I consent to my data being used for the purpose of reviewing and processing my application to the Associate Committee, in line with NAPICU's data protection and privacy policies.
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Associate Member Application Form