IMA Membership Application

Become a member of this growing body of medical and allied health professionals

Consider your annual membership fee a small donation towards the projects and upliftment of communities in need.

Name*
Surname*
Date of Birth
MM slash DD slash YYYY
Residential Address
Postal Address
Practice Address
Tel (Work)
Tel (Home)
Cell*
Email*
Whatsapp Number
Facebook Page
Twitter
Instagram
Website
Profession / Speciality
Registered Council Number
Select
- Doctor, Dentist,, etc
- Allied Health Professionals: Physios, OTs, Podiatrists, Psychologists, Pharmacist, etc
- Medical Intern
- Nurses, Paramedics
- Medical Student - Free
HPCSA Number
Which IMASA branch Committee wud you like to join?
Select
- Are you willing to volunteer your time towards IMASA activities?
Select
- Will you be prepared to write articles of interest for circulation?
Please Note: Rates are subject to increase every year.
Total Due Per Annum:
R0.00
Consent
I agree to the privacy policy.
I do hereby give my consent, to IMASA, to process my personal information as follows:

My contact details including my email address, cell no, work no, physical & postal, HPCSA no etc, to receive relevant information in relation to CPD accredited programmes and other events / project information at IMASA block

Adding me to regional and national whatsapp groups block

Providing my details to sponsors and other third parties who may on occassion require my information block

Providing my details to sponsors and other third parties who may on occassion require my services etc block

in accordance with the provisions of the Protection of Personal Information Act.

Are you willing to volunteer your time towards IMASA activities?

Will you be prepared to write articles of interest for circulation?

Which IMASA branch Committee wud you like to join?