To express your interest in becoming a PACMAT member, please complete the form below. 
Contact Details:

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* 1. Full Name

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* 2. Email

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* 3. Phone

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* 4. City

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* 5. Ethnicity

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* 6. Do you have any dietary restrictions?

Next of Kin Details:

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* 7. Name

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* 8. Phone Number

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* 9. Email address

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* 10. Relationship to you

Employment Details:

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* 11. Current Role

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* 12. Current Employer

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* 13. Employer contact details (please include a name and email address of a representative we can contact regarding your release for a deployment)

Professional Specialty Areas:

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* 14. Please list your speciality areas (e.g. surgical, general, medical, paediatrics etc)

Regulatory details

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* 15. Do you have a current practicing certificate/licence?

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* 16. Regulatory Authority

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* 17. Expiry date

Date

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* 18. Annual Practicing Certificate

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* 19. Do you have current indemnity cover?

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* 20. Indemnity Cover

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* 21. Any restrictions to your working conditions?

Other Relevant Skills & Experience:

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* 22. Previous emergency management or disaster relief training

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* 23. What training have you received? (eg. CIM, CIMS4, NZMAT/AUSMAT).

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* 24. Previous deployment disaster relief experience? 
(include location, role and length of stay)

Uniform:

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* 25. Normal Polo Shirt / T Shirt Size

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* 26. Normal Scrubs Size

Photos on Deployment:

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* 27. Please confirm your approval to use any photos of you for PMA/PACMAT publications.

Attachments Required:

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* 28. Passport

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* 29. Current Curriculum Vitae

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* 30. Immunisation Record

PMA Member

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* 31. Please indicate availability for standby (2024 - 2025 Pacific Cyclone Season)

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* 32. Do you agree to be a member of PMA? (Please select no if you're already a member) Join here.

Agreement & Confirmation:

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* 33.
•  I have read and understood the PACMAT Code of Conduct
•  I give permission for a criminal vetting be completed
•  I give permission for a Working with Children check be completed
•  I understand that I need to be fully vaccinated
•  I understand that information provided in this registration form may be shared with health professional organisations to enable the advance selection and deployment of suitable personnel for deployment(s)
•  I understand that I will need to attend a predeparture briefing in Auckland prior to the deployment unless specifically notified otherwise.

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