EPNS New Membership Application Form

Prove your humanity: 5 + 9 =

If you have any questions, please email info@epns.info

(*) indicates mandatory fields

Title (*)

First name (*)

Last name (*)

Email Address (*)

Work Address (*)

Home Address

Country (*)

Send Society Journal to (*)

Which ONE of the following applies to you? (*)

Fully qualified Medical Doctor/Physician in Paediatric NeurologyFully qualified Medical Doctor/Physician in another field of medicine with an interest in Paediatric NeurologyTrainee/Resident, i.e. a qualified Medical Doctor/Physician TRAINING in Paediatric Neurology or in another field of medicine with an Interest in Paediatric NeurologyNeuroscientist or other Clinical Specialist with an interest in Paediatric NeurologyAllied Health Professional/Nurse with an interest in Paediatric NeurologyPhD Student (full time and not practicing as a physician)Medical Student, i.e. an medical undergraduate with an interest in Paediatric Neurology

Are you a qualified medical doctor/physician? (*)

Are you trained in Paediatric Neurology?(*)

Are you an ALLIED HEALTH PROFESSIONAL/NURSE?
If YES, MANDATORY, you must give the information (a to d) requested below:
a.Job Title
b.Professional registration number
c.Professional body name
d.Professional body website
e.Date of professional registration

Are you a NEUROSCIENTIST OR OTHER CLINICAL SPECIALIST?
If YES, MANDATORY, you must give the information (a to c) requested below:
a.Job Title
b.Qualifications (degree and above)
c.Year started working in this field

Are you a MEDICAL STUDENT, i.e. a medical undergraduate?
If YES, MANDATORY, you must give the information (a to d) requested below:
a.Title of BSc, MSc. or PhD study
b.Current year of study, e.g. 3rd, 4th, etc.
c.Year expected to complete current study
d.I understand I need to send a supporting letter/email from my tutor to info@epns.info

Are you a full time PhD Student i.e. not a practising physician?
If YES, MANDATORY, you must give the information (a to d) requested below:
a.University Name
b.Department Name
c.Year PhD study started
d.Year PhD study expected to be completed
e.I understand PhD Student membership expires in 2 years and I need to contact info@epns.info to renew

If you already have your Tutor supporting letter/email from your tutor upload here (PDF/JPG format - limit 10MB)

If you have any problem or you don’t yet have your Tutor supporting letter, please send by email as soon as it is available to info@epns.info .In the meantime your EPNS membership will be set up, pending receipt of the Tutor supporting letter

Please select your profile from one of the following:(*)

What is your research / clinical interest in paediatric neurology? (*)

Name of National Society (if you are a member of a National Paediatric Neurology Society, otherwise leave blank)

We would also be interested to learn what led you to join EPNS. Please tick the appropriate box (*)

If other ...

(*)I've read the EPNS Privacy Policy [+]

Ordinary membership for qualifying members will be ratified by the Board and approved by a vote at the general meeting of members.
For additional details of the Constitution and Bylaws of the Society, CLICK HERE