EmailMe Form - Medical Personnel Registration

Full Names and Surname *

First Last

ID Number *

HPCSA Registration Number (ONLY registered members)

Other Medical Qualifications

Nationality *

Physical Residential Address *

Postal Code *

Personal Email Address (GMail etc.) *

Mobile Number *

### - ### - ####

WhatsApp Number (Optional)

### - ### - ####

(ONLY if different to Mobile No.)

Home Phone (Optional)

### - ### - ####

Work Phone (Optional)

### - ### - ####

Are you on WhatsApp *

Yes

No

Drivers License *

Additional Drivers License

Do you have a PDP *

Yes

No

Own Vehicle (Specify)

Advanced Driving Skills?

Do you have your own Jump Bag (Fully Equipped) *

Yes

No

Do you have your own O2 *

Yes

No

Do you have your own ALS Drug Bag *

Yes

No

Current Empoyment (Specify) *

Specify Availability (24 hrs, Shift dependant, Weekends, etc) *

Specify Areas for Availability *

Past Event Skills *

Tell me about yourself, by explaining your Personality Skills *