NPPG Membership Form 2018

Membership Form for 1st Jan 2018 to 31st December 2018

If paying by cheque please send your payment to: NPPG Administrator, c/o Profile Productions. Boston House, 69-75 Boston Manor Road, Brentford, TW8 9JJ. Details for paying Standing Order can be found further down this form.

Click here to open a printable copy of payment options

As part of your membership you will be registered on the NPPG Message Board. Current members who have not renewed prior to the 31st March 2018 will have their name removed from the message boards

Membership enquiries - Tel no: 020 3725 5840 admin@nppg.org.uk

Question Title

* 1. Type of application

I am renewing my membership

I am a new member

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* 2. Name

Title

Surname

Forename

Member number (if renewing)

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* 3. Preferred contact address and details

Institute

Department

Street

Town

County

Post Code

Country

Telephone number

Email address

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* 4. Description

Pharmacist

Technician

Other

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* 5. Type of pharmacist / technician - main job role

Hospital

Community

Industry

Academic

Regulatory

Consultant

Other (please specify)

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* 6. band / Grade

Lecturer

Other (please specify)

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* 7. Main area of practice

Paediatric hospital

Maternity Hospital

Paediatric / Neonatal unit within DGH

Paediatric / Neonatal unit within Teaching hospital

University

Home

Other (please specify)

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* 8. Are you a member of the Royal Pharmaceutical Society of Great Britain

Yes

Not applicable

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* 9. If Yes to previous question what stage of Faculty member ship are you at?

Not planning to join

Thinking about joining

Working on portfolio

Stage I faculty member

Stage II faculty member

Faculty Fellow

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* 10. Data sharing

Tick to receive the newsletter / other mailings via the NPPG website only

Tick for NPPG members to have access to your details

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* 11. Subgroup membership (no extra cost)

I wish to become a member of the Paediatric Oncology Pharmacists (POP) group

I wish to become a member of the Paediatric Intensive Care Pharmacists (PICU) Group

I wish to become a member of the Neonatal Intensive Care Group

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* 12. NPPG is setting up regional groups in Great Britain to help members interact locally. Please select the regional group you feels best meets your geographical needs (you can choose more than one)

South West

South Central

South East

London

East Anglia

East Midlands

West Midlands

Wales

North West

North East

Scotland (SNAPP)

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* 13. NPPG is frequently asked to respond to consultations and scoping events for guideline development, particularly in relation to NICE Guidance. If you would be interested in hearing about opportunities to be considered for this work then please tick

Yes

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* 14. Please indicate below by ticking any appropriate boxes your interests and personal specialities. This data may be used by the group to put people in touch with you if they need advice or if they are doing a particular study. (None of us know everything so please don’t be shy)

	Interested	Specialist	Willing to respond to consultations on the subject
Neonates	Neonates Interested	Neonates Specialist	Neonates Willing to respond to consultations on the subject
Paediatrics	Paediatrics Interested	Paediatrics Specialist	Paediatrics Willing to respond to consultations on the subject
Paediatric Chemotherapy	Paediatric Chemotherapy Interested	Paediatric Chemotherapy Specialist	Paediatric Chemotherapy Willing to respond to consultations on the subject
Drugs In Pregnancy and Lactation	Drugs In Pregnancy and Lactation Interested	Drugs In Pregnancy and Lactation Specialist	Drugs In Pregnancy and Lactation Willing to respond to consultations on the subject
Off Label/orphan Drug Use	Off Label/orphan Drug Use Interested	Off Label/orphan Drug Use Specialist	Off Label/orphan Drug Use Willing to respond to consultations on the subject
Paediatric/Neonatal Nutrition	Paediatric/Neonatal Nutrition Interested	Paediatric/Neonatal Nutrition Specialist	Paediatric/Neonatal Nutrition Willing to respond to consultations on the subject
Palliative Care	Palliative Care Interested	Palliative Care Specialist	Palliative Care Willing to respond to consultations on the subject
Pain Control	Pain Control Interested	Pain Control Specialist	Pain Control Willing to respond to consultations on the subject
Paediatric Intensive Care	Paediatric Intensive Care Interested	Paediatric Intensive Care Specialist	Paediatric Intensive Care Willing to respond to consultations on the subject
Paediatric Renal	Paediatric Renal Interested	Paediatric Renal Specialist	Paediatric Renal Willing to respond to consultations on the subject
Paediatric Cardiology	Paediatric Cardiology Interested	Paediatric Cardiology Specialist	Paediatric Cardiology Willing to respond to consultations on the subject
Paediatric Neurology	Paediatric Neurology Interested	Paediatric Neurology Specialist	Paediatric Neurology Willing to respond to consultations on the subject
Paediatric Liver	Paediatric Liver Interested	Paediatric Liver Specialist	Paediatric Liver Willing to respond to consultations on the subject
HIV / Aids	HIV / Aids Interested	HIV / Aids Specialist	HIV / Aids Willing to respond to consultations on the subject
Formulations	Formulations Interested	Formulations Specialist	Formulations Willing to respond to consultations on the subject
Cystic Fibrosis	Cystic Fibrosis Interested	Cystic Fibrosis Specialist	Cystic Fibrosis Willing to respond to consultations on the subject
Respiratory	Respiratory Interested	Respiratory Specialist	Respiratory Willing to respond to consultations on the subject

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* 15. Payment options

I will forward a cheque payable to NPPG membership to NPPG Administrator, c/o Profile Productions. Boston House, 69-75 Boston Manor Road, Brentford, TW8 9JJ.

I have set up a Standing Order for the NPPG account at the HSBC. Account number 21380273. Sort Code 40-29-26

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* 16. Payment amount

£35 – for renewals or new memberships received before 31st March 2017

£45 – for renewals or new memberships received after 31st March 2017

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* 17. Tick this box to signify that you will comply with NPPG policies - details here

Yes