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Contact address and telephone number

By Joyce Gibson,2014-06-01 07:54
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Contact address and telephone number

    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

Address:

Postcode: ;

    Tel:

    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. COTSSOlder 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 COTSSOlder 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 &

    Emergency

    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)

Card Number

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”

    Signed Date

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

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