NECPAM - Membership application form

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Criteria for consideration for NECPAM membership: (A) indicated interest in the area of addiction medicine - including medicine, psychiatry, paramedical and allied professions (i.e. nurses, clinical psychologists, medical researchers, social workers, etc) AND one of two: (B) in countries with formal training in addiction medicine for the specialty of the nominee: up to 10 years after finishing training in addiction medicine; OR (C) In countries without formal training in addiction medicine for the specialty of the nominee: up to 10 years after finishing other type of formal training required for practicing in addiction medicine (e.g. psychiatry residency)

Full name *

TITLE *

Prof.

Dr.

Mrs.

Ms.

Mr.

Other:

Required

GENDER *

Female

Male

Required

JOB *

Academic

Community health worker

Government official

Health care administrator (with overall managerial functions)

Nurse

Phyisician

Policy maker

Politician (official of an international organization, such as UN)

Psychiatrist

Psychologist

Researcher

Representative of a NGO

Representative of a professional association

Other:

Required

DATE OF BIRTH *

YYYY

COUNTRY OF RESIDENCE *

AFFILIATION *

E-mail address *

OTHER CONTACT DETAILS

AREAS OF PROFESSIONAL INTERESTS *

YEARS OF EXPERIENCE IN ADDICTION MEDICINE *

TOPIC OF INTERESTS IN THE NETWORK *

Choose as many as applicable

Alcohol

Drugs

Addictive behaviours

Other:

Required

MEMBERSHIP *

Associate member (stay in touch with the network, and remain informed of activities)

Full member - exclusive for Early Career Professionals in Addiction Medicine (stay in touch with the network, remain informed of activities, play an active role in at least one of the networks’ project within a specific working group, and contribute to the overall network development)

WORKING GROUP OF INTEREST *

WG1 - Promotion

WG2 - Development

WG3 - Collaboration

WG4 - Training gaps

WG5 - Education

Would like to lead additional working group

Other:

Required

I hereby would like to express my wish to join the NECPAM as a MEMBER/ASSOCIATE and agree to follow its code of ethics and comply with the vision and mission of the network *

AIM: This global interdisciplinary network aims to strengthen leadership and build capacity for future public health and clinical practice in the field of addiction medicine by establishing a platform for sharing experiences and empowering early career professionals.VISION: Global development of future system of prevention and treatment for disorders related to substance use and addictive behaviours through close and global co-operation between early career professionals and mentors working in the field.MISSION: Connecting, empowering and facilitating evolution of early career professionals working in the field of addiction and related disorders worldwide. This is going to be achieved by promoting high level of knowledge and professional ethic, respect of diversity and human rights; facilitating peer-lead research and practical initiatives at both local and international levels; working towards reducing stigma associated with addiction and related disorders. MAIN PRINCIPLES AND VALUES. Mutual respect, friendship, openness, equity, dialogue, sensitivity to diversity and differences in cultural traditions, highest level of clinical competence, human rights, destigmatizing practices of care.

I agree

Required

Thank you for applying for NECPAM membership.

We will consider your application and be back to you.
If you have further questions please contact: contact@necpam.com

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