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					                                        Australian & New Zealand Association for
                                        Health Professional Educators
                                                                                                                     ABN 57 130 154 650
                                  MEMBERSHIP APPLICATION/RENEWAL 2012
                                      (Membership Year 1 April 2012-31 March 2013)
Name

Address

Tel                                                                         Fax

Email                                                                       Student no. (if applicable)

What health professional education program(s) are you involved with?
      Medical/Health Education                 Medicine          Dentistry         Psychology        Allied Health
      Nursing/Midwifery              Paramedic           Pharmacy         Health Sciences         Other



                                                 SUBSCRIPTION FEES (incl. GST)
Membership includes a subscription to Focus on Health Professional Education: A Multidisciplinary Journal
and the ANZAHPE Bulletin (available from the ANZAHPE website (www.anzahpe.org).

       Individual Membership (12 months)         AU$220            Institutional Journal only                               AU$300
       Individual Membership (6 mths or less, applies after 1 Oct each year)    AU$110
       Student Membership (12 months)*                        AU$80               Corporate Membership **                   AU$700

* Student membership is available to full time students only
** Please provide a list of the names and email addresses of the five individuals covered by your corporate membership and nominate one
     individual to vote at the Annual General Meeting.

Corporate Members Names & Email Addresses
1)                                                                        2)
3)                                                                        4)
5)

                                                         METHOD OF PAYMENT
           Payment by cheque (payable to “ANZAHPE”) or credit card should be sent to the address below.
                            New Zealand members - credit card payment is preferred.



Please debit my Visa / Mastercard Number:


Expiry Date             /                                for the Amount of:       AU$

Cardholder Name:
(BLOCK LETTERS)                                                                Cardholder Signature:


                                          Please retain a copy for your records and return form to:
                            Ms Jill Romeo, ANZAHPE Office, c/- Health Professional Education, Flinders University,
                                               PO Box 852, RENMARK, South Australia, 5341
                                  PH: 0478 313 123; FAX: (08) 8586 3 668; EMAIL: anzahpe@flinders.edu.au
                               Australian & New Zealand Association for
                               Health Professional Educators
                                                                                                            ABN 57 130 154 650

1. Members Interest and Research Areas                                  NAME:

                                                    I have an interest        I have research          I would be willing to
                                                        in this area          expertise in this        supervise or mentor
                                                                                    area               a young researcher
                                                                                                           in this field
   Admission / Selection
   Assessment / Testing
   Basic Science Education
   Career Choice
   Clinical Skills Education
   Communication Skills
   Computers, Simulation & E-Learning
   Continuing Health / Medical Education
   Curriculum Development & Evaluation
   Evaluation & Assessment of Clinical
   Performance
   Faculty Development
   Health Promotion & Management
   Instructional Materials / Methods
   Interprofessional Education
   Medical Humanities
   Personal Characteristics / Attitude
   Postgraduate Education / Training
   Primary Care Education
   Problem Based Learning
   Professional Development & Ethics
   Qualitative Research Methods
   Quantitative Research Methods
   Safety & Quality in Health Care

   Other (Please Specify)

   2. Your role(s) in health professional education eg Director of Clinical Education (Hospital? University?)
   1)

   2)

   3)
                                 Please retain a copy for your records and return form to:
                   Ms Jill Romeo, ANZAHPE Office, c/- Health Professional Education, Flinders University,
                                      PO Box 852, RENMARK, South Australia, 5341
                         PH: 0478 313 123; FAX: (08) 8586 3 668; EMAIL: anzahpe@flinders.edu.au

				
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