New Membership Form

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New Membership Form

First Name *

Last Name *

Email *

Address *

Post Code *

Contact Phone Number *

Place of Work [Hospital] *

Specialty *

Anaesthetics

PACU

Required

Membership Type *

Full

Student

Group Leader

If Student: Please Provide Training Course, College, and Finish Date

If Group Leader: Please give name and email addresses of other two group members.

Note – a single payment for the group is to be made by the Group Leader. The other group members need not fill in a form. They will receive information directly through their email and or their group leader.

Role *

Registered Nurse

Associate Nurse

ODP

Non-Registered Health Care Professional [HCA]

Doctor

Lecturer / Trainer

Other:

Payment *

BACS Payment: via Membership Secretary

Paypal

Standing Order (please put your postcode and surname in the reference box on your bank’s Standing Order Form)

I consent to have BARNA store my information in order to register for Membership. BARNA does not keep any personal bank card payment details on record. I also consent to receive BARNA’s membership emails to my email address [See section on Data Protection Policy].
*

I consent

Required

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