Australian Allied Health in Palliative Care Membership Form

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First Name *

Last Name *

Profession *

Dietitian

Physiotherapist

Psychologist

Social Worker

Speech Pathologist

Occupational Therapist

State *

Australian Capital Territory

New South Wales

Northern Territory

Queensland

South Australia

Tasmania

Victoria

Western Australia

Other Country (Please list Country and State):

Workplace *

Position *

Email *

Highest Level of Education *

Diploma

Undergraduate Degree

Undergraduate Degree with Honours

Postgraduate Certificate

Postgraduate Diploma

Masters

PhD

Other

Educational Qualifications *

(Please state your educational qualifications e.g. Masters of Occupational Therapy)

Place of Degree/s *

(Please list all relevant university institutions)

Clinical interest areas *

(Please list any specific areas of special interest)

Have you completed any research? *

Yes

If yes, please state topic of research

Do we have your permission to share the above information with the members of AAHPC? *

(NB. If you select no, your information will not be shared with peak bodies or put on any member distribution lists)

Yes

Submit

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