Membership Registration Form

HiPPP EMR-C Membership Registration Form

Step 1 of 2

What is your title and full name(Required)

What are your pronouns?

(Please indicate in the text box below, leave blank if you prefer not to disclose)

What is your ethnicity?(Required)

Other(Required)

What is your email address?(Required)

What is your X handle?

What is your LinkedIn Profile?

What are your affiliation/s (i.e. workplace, research or educational institution)?(Required)

If your affiliation is in Australia, what are the state/s of your affiliation/s?(Required)

Other(Required)

If your affiliation is in New Zealand, what are the state/s of your affiliation/s?(Required)

Other(Required)

Please indicate why you are interested in joining HiPPP EMR-C.(Required)

Research collaboration

Networking

Access to other research in my field

Future opportunities

What is your research career stage?(Required)

Other(Required)

Which are your main population/s of work or research?(Required)

Other(Required)

What type of interventions/exposures do you have knowledge of or experience in?(Required)

Other(Required)

What level of participation do you see yourself having in HiPPP EMR-C?(Required)

Attending (online) the quarterly research showcases

Attending (face-to-face or online) the annual HiPPP EMR-C conference

Having an active role in the HiPPP EMR-C leadership committees

If you are interested in HiPPP EMR-C mentorship program, which role/s would you prefer?

Mentee

Mentor

Not at the moment

What valuable skills, network, or knowledge can you bring to the HiPPP EMR-C?(Required)

How did you find out about HiPPP EMR-C?(Required)

Other(Required)

Join our mailing list to ensure you do not miss out on important news and communications from HiPPP EMR-C, including annual conference and our quarterly newsletter(Required)

Yes please. Sign me up to receive important news and communications from HiPPP EMR-C

No, I would not like to receive communications this time

Are you interested in joining our team of co-leads? These roles allow EMCRs to develop a range of skills and network with other members of the community.(Required)

Yes, I am interested

No, I am not interested

Student and Part-Time Memberships
Student and part-time membership rates can be requested by including a letter of support from your supervisor confirming your student or part-time work status with your membership application. Please email hippp.emrc@hipp.org.au to discuss pro-rata fees for part-time work.

Membership Type(Required)

Letter of Support

A letter of support is required for all student and part-time membership applications. Please email hippp.emrc@hipp.org.au with any queries.
**Please ensure all student/part-time applications include a letter of support. Applications without this evidence may be rejected.**

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.

Payment options include Paypal and bank transfer. If you wish to pay via bank transfer, please email hippp.emrc@hipp.org.au BEFORE submitting your form.

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Total

Centre of Research Excellence
Health in Preconception & Pregnancy

Centre of Research Excellence
Health in Preconception & Pregnancy

Centre of Research Excellence
Health in Preconception & Pregnancy

Centre of Research Excellence
Health in Preconception & Pregnancy

HiPPP EMR-C Membership Registration Form

HiPPP EMR-C Membership Registration Form

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