PERUKI Individual Membership Application Form
** MAY 2019 - WE HAVE MOVED TO A FULLY ELECTRONIC REGISTRATION PROCESS - ALL MEMBERS ARE REQUIRED TO RE-REGISTER TO ASSIST WITH THIS **


This form is to be used by individuals who wish to become PERUKI members. Individual membership is free, but members must agree to abide by the terms and conditions laid out in the PERUKI governance document.

Please note: to complete your PERUKI membership, after completing this form you must go to the members area at www.peruki.org, where you will be asked to create an account for the website. One of the team will then approve your website access (this may take a few days as the account is not checked daily).
Email address *
Title *
First Name *
Surname *
Job Title *
Professional group (please select an answer closest to your primary role) *
Department *
Institution - Name & Address
If your institution is a registered PERUKI site, please select it from the drop-down list below and then continue with the contact telephone number question.

If you work at an institution that is not a registered PERUKI site, please select "Other" from the drop-down list and provide details within the subsequent 3 questions.
Institution (select either your official PERUKI site or "other") *
Other sites - Institution Name
Other sites - Institution City
Non-PERUKI sites - Institution Country
Clear selection
Preferred contact telephone number
Do you have any specific areas of research interest within PEM?
Please outline any additional research responsibilities/roles that you have which may be relevant to PERUKI
Statement: I agree to abide by the terms and conditions of the group as laid out in the document “Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI) Operational Policy” (available from http://www.peruki.org/) *
Signed *
Date (DD/MM/YY) *
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