Join UsDo you need immediate help? Yes NoEnter GMC Number*(Required)if you do not enter a valid GMC number you may receive an acknowledgement but will not receive a substantive responseTitle*(Required)First Name*(Required)Middle Name(s)Last Name*(Required)Personal Email Address*(Required) Contact Number*(Required)Date of Birth*(Required) Place of Birth*(Required)Registered Qualifications*(Required)Speciality*(Required)Address (House No. & Street)*(Required)Address (Town)*(Required)Select County*(Required)SelectBath and North East SomersetBedfordshireBerkshireBristolBuckinghamshireCambridgeshireCheshireCornwallCounty DurhamCumbriaDerbyshireDevonDorsetEast Riding of YorkshireEast SussexEssexGloucestershireGreater LondonGreater ManchesterHampshireHerefordshireHertfordshireIsle of WightIsles of ScillyKentLancashireLeicestershireLincolnshireLondonMerseysideNorfolkNorth SomersetNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOxfordshireRutlandShropshireSomersetSouth GloucestershireSouth YorkshireStaffordshireSuffolkSurreyTyne & WearWarwickshireWest MidlandsWest SussexWest YorkshireWiltshireWorcestershireAberdeenshireAngusArgyll & ButeAyrshireBanffshireBerwickshireBordersCaithnessClackmannanshireDumfries & GallowayDunbartonshireEast AyrshireEast DunbartonshireEast LothianEast RenfrewshireFifeHighlandInverclydeKincardineshireMidlothianMorayNorth AyrshireNorth LanarkshireOrkneyPerth & KInrossRenfrewshireShetlandSouth AyrshireSouth LanarkshireStirlingshireWest DunbartonshireWest LothianWestern IslesBlaenau GwentBridgendCaerphillyCardiffCarmarthenshireCeredigionConwyDenbighshireFlintshireGwyneddIsle of AngleseyMerthyr TydfilMonmouthshireNeath Port TalbotNewportPembrokeshirePowysRhondda Cynon TaffSwanseaTorfaenVale of GlamorganWrexhamAntrimArmaghDownFermanaghLondonderryTyronePostcode*(Required)Medical School*(Required)Date of graduation*(Required) Current Role*(Required)SelectConsultantCoronerGPHospital DoctorIn trainingMedical LeadershipMedicolegal AdvisorRetiredOtherDefine Role*(Required)Spouse / Partner*(Required) Yes NoSpouse's / Partner's Name*(Required)Spouse's / Partner's Date of Birth*(Required) Children/Step Children/Dependents*(Required) Yes NoAdd Children 1/Step Children 1/Dependents Name and Date of Birth *(Required)Please enter date in this format - dd/mm/yyyyAdd Children 2/Step Children 2/Dependents Name and Date of BirthPlease enter date in this format - dd/mm/yyyyAdd Children 3/Step Children 3/Dependents Name and Date of BirthPlease enter date in this format - dd/mm/yyyyAdd Children 4/Step Children 4/Dependents Name and Date of BirthPlease enter date in this format - dd/mm/yyyyAdd Children 5/Step Children 5/Dependents Name and Date of BirthPlease enter date in this format - dd/mm/yyyyAdd Children 6/Step Children 6/Dependents Name and Date of BirthPlease enter date in this format - dd/mm/yyyyDeclarations(All sections mandatory)Do you know of any circumstances which have or may affect your ability to work?*(Required) Yes NoPlease provide more details.*(Required)Have you had, or do you have pending, any dispute, regulatory, disciplinary or litigation issues?*(Required) Yes NoPlease provide more details.*(Required)I agree to Gift Aid my subscription fee and any other donations I might make now or in the future to SAMF (I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference) Yes NoDeclarations(Required) I hereby declare that I would like to become a Member of the Society for Assistance of Medical Families.(Required) I declare that the particulars given on this form, are a true statement of my circumstances.(Required) I consent to receive email communication from SAMF and communicate with SAMF by email for the purposes of member communications and the administration of SAMF.(Required) I consent to SAMF Trustees and staff processing and storing my personal data both provided on this form and included in any communication from me, my doctor, or other healthcare professionals.(Required) I confirm that I have read the Privacy Policy and understand how my personal data will be collected, used and stored.(Required) I am aware that SAMF may investigate and may take further action on any application that appears fraudulent or is considered to be deliberately misleading.(Required) I would like my name and county location to be visible on the Annual List of Members, available only to fellow MembersWhere did you hear about us?(Required)MemberWelfare AdvisorAnother CharityInternet SearchOtherEnter Source(Required)SAMF confirms that it holds all data it receives securely and in accordance with Data Protection principles. SAMF is registered with the Information Commissioner: Reg.no. Z8236493Signature*(Required)Date*(Required) CAPTCHA
