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Recognising Our Black Nurses and Midwives 2020
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Who Can Join CATSINaM
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Personal Details
Title
-- Select an answer --
Dr
Professor
Mr
Mrs
Ms
Miss
Organisation
Associate Professor
Firstname
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Address
Town
State
-- Select an answer --
ACT
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Postcode
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Best Contact Number
I identify as
Aboriginal
Torres Strait Islander
Both
Non Aboriginal
Date of Birth
Your clan/group/nation/language
Please explain your links to Country
Type Of Membership
Type of Membership you are applying for?
Full Membership (an Aboriginal and Torres Strait Islander Person and an Enrolled Nurse, Registered Nurse, Registered Midwife and Maternal Infant Care Practitioner). Membership if free.*
Student Membership (an Aboriginal and Torres Strait Islander Person and a Student Enrolled Nurse, Student Registered Nurse, Student Midwife). Membership is free.
Associate Membership (an Aboriginal and Torres Strait Islander Person and an Assistant in Nursing, Retired Enrolled Nurse, Retired Registered Nurse, Retired Midwife). Membership is free.
Affiliate Membership (Individual) must identify as Aboriginal and Torres Strait Islander.
Other Questions
If Registered, Registration Number
Note: If you selected Full Membership please provide us with this number
If Retired, what year did you retire?
Are you a student?
Yes
No
Other (please specify)
For Students, where is your place of study?
What year did you commence your study?
Year attained?
What year will you complete your study?
What qualifications do you have?
If Employed, What is your current employment sector?
Public Health
Hospital
Student
Aboriginal Health Service
Research
Academic/Education
Specialist (Please specify)
Government/state/territory
Private
Other (please specify)
Other employment sector (please specify)
Where is your place of employment?
What is your job function?
Nurse
Midwife
Lecturer
Student
Nurse Practitioner
Eligible Midwife
Consultant
Allied Health Worker
Enrolled Nurse
Assistant in Nursing
Public Service
Aboriginal Maternal Infant Care Practitioner (AMICP)
Other
Other job function (please specify)
Terms and Conditions
Student confirmation: I agree to the CATSINaM Membership Terms & Conditions
Yes
I hereby declare that I am an Aboriginal and/or Torres Strait Islander person and recognized as such by my community and understand that this may be investigated further
Yes
I hereby declare that the information provided in this application is true and accurate to the best of my knowledge
Yes
I hereby declare that I have read and will abide by the CATSINaM Constitution
Yes
I agree to the use of my personal information for the purposes of CATSINaM, its secretariat and board, communicating on CATSINaM matters
Yes
As a member of CATSINaM I agree to pay an amount up to $10 on the winding up of the company if required.
Yes
I agree to have my details saved
