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Membership

APPLICANT’S DETAILS

Last Name:

First Name:

Occupation/Position:

Institution/Employer:

Postal Address:

Post Code: Country:

Telephone:

Facsimile:

Mobile:

Email:

Health or social care discipline (e.g. nurse, social worker):

Area(s) of interest related to family carer research (e.g. intervention studies):

Specific research skills/experience (e.g. qualitative analysis):

IPCFRC initiatives that I am most interest in contributing to:

Individuals from all continents with a genuine interest in palliative care research related to family carers may become individual members of the IPCFRC. There is no membership fee. To formalise your membership please complete the details below.

POST, FAX OR EMAIL REGISTRATION FORM TO:

Postal: International Palliative Care FamilyCarer Research CollaborationC/- Centre for Palliative CareSt Vincent’s Hospital Mailbox 65PO Box 2900Fitzroy Victoria 3065 Australia

Fax: +61 3 9231 1202Email: centre.palliativecare@svha.org.auWeb: http://ipcfrc.centreforpallcare.org

OFFICE USE ONLY DATE RECEIVED: MEMBERSHIP NO.: RECEIPT NO.:

Institutions may apply for organisational membership status by writing to the IPCFRC Executive Committee at at centre.palliativecare@svha.org.au, outlining how their organisation is proposing to assist the IPCFRC. Organisational members are typically offered formal recognition of their contribution via acknowledgment in relevant marketing and correspondence.