Membership application

To apply to join Pride in Medicine Australia and Aotearoa NZ please fill out our membership form.

Questions? Email us at membership@prideinmedicine.com

Section 1 - Required information

Name

First Name

Last Name

Preferred name

Pronouns

Country

State (Aus)/Island (NZ)

We will maintain contact with members primarily via email, but we also have a moderated facebook community for members which offers the chance to discuss rainbow health topics ask questions and connect with colleagues. Please tick the box below if you would like to join this group AND enter the email address associated with your facebook account.

I would like to join the Pride in Medicine facebook community

Email associated with my facebook account:

Section 2 – Confirm role as a doctor/medical student

You will need to provide one of the following to enable us to process your application

– AHPRA or MCNZ registration number
– Student ID or letter showing you are a current medical student
– A 5 minute video chat to confirm your identity

OPTION 1: Registered name and registration number (AHPRA or MCNZ)

OPTION 2: Student ID/letter showing you are a student enrolled in medicine

Upload

OPTION 3: I am unable to provide registration or student ID, please contact me to arrange a brief video chat to confirm by identity

I am unable to provide proof

Section 3 – Optional information

We appreciate you filling in this information to help us understand more about our membership – it will only be used in de identified aggregate form (please see our privacy statement below)

Which best describes you?

Ethnicity/Ethnicities

Gender identity

Stage of training (select one)

What specialty are you currently training/trained in?

Please list any specialties you are currently training in or have fellowship in.
If you have not yet specialised write “no specialty.

If you have any college associations please list them here:

What areas of PiM are you interested in?

Events

Networking

Activism

Education

Support

We are gauging interest in a mentorship programme. If it were available, would you be interested in taking part in a mentoring program?

If you answered yes, would you take part as a

Please read and agree to our privacy statement

I agree to the privacy statement

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