VicREN Membership Form

VicREN is for people interested in primary care research and education. Membership is free and without obligation.

If you wish to become a member, please complete the form below:

I am a... *

• Primary health care provider or health care professional
• Community member, carer or patient

Your Salutation

-- Please Select --A/ProfDrMrMrsMsMxProf

Your Full Name *

Your Profession

Your Qualifications

Your Workplace

Your Address: Street Address Primary care providers, please provide your workplace address

Your Address: Suburb, City or Town Primary care providers, please provide your workplace address

Your Address: State Primary care providers, please provide state of your workplace

-- Please Select --ACTNSWNTQLDSATASVICWA

Your Address: Postcode * Primary care providers, please provide your workplace postcode

Phone Number

Fax Number

Email * (Must be provided to receive e-bulletins)

Alternate email

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What are your areas of interest? *

• Abuse and violence
• Aged care
• Cancer
• Children and young people
• Chronic disease
• Complementary/Integrative medicine
• eHealth, information technology and data
• Health Services Improvement & Implementation
• Aboriginal & Torres Strait Islander health
• Infectious diseases
• Mental health
• Preventative health care
• Sexual and reproductive health
• Women’s and newborn health
• Other

If other, please specify:

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Would you like to know more about being part of an advisory or special interest group? *

• Yes
• No

Do you already supervise, or are you interested in supervising, medical students at your practice?

Note: We only accept as supervisor General Practitioners who are working at an accredited GP clinic and who are themselves accredited either as a Fellow of RACGP or ACRRM or are vocationally registered.

• Yes
• No

What prompted you to join VicREN?