Membership Form – PatchSA

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PatchSA welcomes any families, caregivers and child-caring professionals including paediatricians, GPs, nurses, social workers, allied health practitioners, psychologists, counsellors, teachers and clergy to join us.

Please select *

First Name (for Companies /Organisations please give name of contact person) *

Surname *

Email *

Cellphone number *

Membership Category *

I am a: *

If 'other' please state:

Do you have a qualification in children's palliative care?

If you answered 'yes', please state your qualification in children's palliative care *

Other paediatric palliative care qualification:

Job Title *

Place of Employment (or Name of Company/Organisation) *

If you are a doctor, nurse, or allied health professional (e.g. physiotherapist) , would you like to join the Whatsapp group?

Yes, please
No, thank you

Postal Address *

Comment or Message

Make Me A Member *

I/ we wish to become a member of PatchSA and agree to abide by the terms of membership as set out above.

Message

Once you’ve submitted your form please use our payment details on this page in order to fund your membership. We accept EFT, Snapscan and Zapper. We’ll be in contact via email as soon as your submission reaches us. Thanks!

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