Associate Member Application - Prehospital Care Research Forum at UCLA
10990 Wilshire Blvd., Suite 1450
Los Angeles, CA 90024

Associate Member Application

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* Applicant

Name *

Employer/Agency *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number (mobile preferred) *

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* Degree(s) / Certification(s)

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* Why do you wish to be involved in the Research Forum?

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* In what area(s) of prehospital care research do you have personal or professional interests or experience?

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* What do you feel should be the primary goals of the Research Forum in the next three years?

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* Indicate the committee(s) in which you wish to participate:

Abstract Review | All new Associates will be asked to participate on the Abstract Review committee their first year. New Associates may select an additional committee if interested.

Education | The Education committee works to create modular programs and develop methods for transferring a wide range of curricula to other centers.

Communication | The Communication committee is dedicated to increasing and maintaining communication of events and ideas by, between, and among PCRF corporate sponsors and PCRF members. Please indicate in the box below if you have experience as a public information officer or with social media handling. If none, leave blank, or select response and indicate "no experience."

Communications experience details

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* Outline any research in which you have participated and your role.

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* Application completion

Curriculum Vitae will be submitted to: pcrf@mednet.ucla.edu

Thank you for your interest in the Prehospital Care Research Forum.

For more information, visit the website: www.pcrf.mednet.ucla.edu or call (310)572-2090.