Membership Application Form 2011
? Henry Grant/Mary Evans Picture Library
Section A Your Contact Details Please write in Capital Letters throughout this form
Office use: Membership Number:
Title First name Surname
Email address: Please ensure the email address is completed correctly to facilitate future contact
Grade or Post:
Data Protection Statement: By providing any of the contact details above, you are authorising the COTSS-Older People National Executive committee members and their authorised agents, to contact you with details relevant to your COTSS-Older People membership and for those details to be networked to other COTSS-Older People members. COTSS–Older People will not disclose your personal details to any outside person or body without your permission. If you do not wish to be contacted by COTSS-Older People by post, email or otherwise with items that are not directly COTSS–Older People related, please tick this box.
Section B About You
COT Regional Group to which you are affiliated (Please tick one only) Eastern Ireland London North West Northern/Yorkshire Northern Ireland Scottish Central Scottish Eastern Scottish Northern Scottish Western South East South West Trent Wales West Midlands European Union International Not applicable
Employer (Please tick all that apply)
Health (PCT) Health (Hospital Trust) Health (MH Trust)
Local Authority Education Independent
Student Other (please specify) Area of Work (Tick all that apply)
Hospital Community Day Care
Social Services Care Homes Intermediate Care
Research Education Independent
Mental Health Rehabilitation Unit Emergency Care
Student Other (please specify)
Section C Clinical Forums
The clinical forums enable members working in the same specialty to network with, provide learning opportunities, and support each other. Each clinical forum has a representative on the NEC.
You can choose to join as many of the forums as you wish, and there is no additional
cost as forum membership is included within the membership fee. Additional information will then be sent to you.
Please indicate which forum(s) you would like to join.
Care Homes Network Dementia Acute Care &
Falls Intermediate Care Mental Health
If you would be interested in becoming a book reviewer for the Specialist Section
Newsletter, please tick this box:
Section D Membership Category (Please tick as appropriate) Professional Member BAOT Number: ?30 OT Support Worker Member BAOT Number: ?10 Retired Member BAOT Number: ?10 Student Member (undergraduates) College Name: ?10
Method of Payment
Credit/Debit Card Please complete the details below
Card type: Visa / Mastercard / Maestro (please delete as necessary)
Expiry Date of Card ……/…….
Maestro Card holders only - please also state the issue number or valid from date: ……/…….
Card Security Code
Name on Card ………………………………………………………..
I enclose a cheque for ?
made payable to “COT Specialist Section – Older People”
Please return completed form to: Selvin Ennis, Specialist Section Membership
Administrator, College of Occupational Therapists, 106-114 Borough High Street,
London SE1 1LB
Please inform the administrator if your details change at any time.
Office use only: Date received:
Cheque number: Date processed: Cheque value:
? College of Occupational Therapists Ltd. Registered in England No 1347374 Registered Charity No 275119