Membership form

Membership Type	*
First name	*
Last name	*
Date of Birth (dd/mm/yyyy)	*
Sex	*	: Male : Female
Title	*
Qualifications with dates	*
Current hospital post	*
Hospital / Institute	*
Address	*
Town / City	*
Postcode	*
Country	*
Telephone
Email	*
Do you hold ultimate responsibility for patients?	*	: No : Yes
Is your practice solely confined to children?	*	: No : Yes
If not, what proportion of your time is occupied looking after adults? (%)
How long have you held your present position? (Months / Years)	*
If you are applying for Associate Membership, is your current appointment a training post in paediatric surgery?	*
State any other Paediatric Surgical Associations of which you are a member	*
Please provide the name and address of a paediatric surgeon who is a member of BAPS who is prepared to support your application (for UK applicants this should be a UK surgeon. For overseas applicants this should be a surgeon in your own country)	*