Geriatric Emergency Medicine Network
Membership Application
Name
*
First Name
Last Name
Email
*
ACEM Membership Number
What is your primary professional classification?
*
FACEM
ACEM Trainee
ACEM Certificant
ACEM Diplomate
ACEM Advanced Diplomate
ACEM SIMG
Allied Health Worker
Geriatrician
Medical Officer/Intern
Medical Administration
Nursing Staff
Other Specialty Consultant
Other Specialty Trainee
Paramedic
Research Staff
Other (Please specify)
Are you any of the following?
*
Director of Emergency Medicine (DEM)
Director of Emergency Medicine Training (DEMT)
None of the above
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
Primary place of employment?
*
Please tell us about any special interests you have that may be relevant to this Network (clinical/research/other)
*
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.
Submit
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