Online Survey Software | Qualtrics Survey Solutions

NT Clinical Academy Membership application form

The Northern Territory Clinical Academy (Academy) provides a forum on matters related to medical education and training with a focus on the challenges and opportunities of practice within the Northern Territory (NT). The Academy aims to enhance clinical learning along the pathways of medical training, in both acute and primary health care.

- You will be joining an NT centric community of practice of medical clinical educators.
- Members can take advantage of the opportunities to collaborate with innovative mechanisms that assists your personal learning.
- Reduction of the challenge of professional and geographical isolation by connecting the knowledge and skills existing in a variety of locations and with separate groups and individuals.
- Opportunity to participate in Territory wide and regional networking events.
- The Academy is open to all medical clinicians who have an interest in clinical education within the Northern Territory.

Please forward any enquiries to fnt.rth@flinders.edu.au

Title:

Given Name:

Surname:

Email:

Mobile:

Current job title:

Employer/Organisation:

In which locations would you like to attend events (tick all that apply):

Please specify any sub-specialties or areas of expertise (if applicable):

Do you hold current academic status with any institution? If yes, please advise name of the institute and your role:

Number of years delivering clinical education:

If applicable, what cohort of learners do you currently deliver clinical education to?

What specific areas in clinical education are you most interested in learning more about or receiving support in?

If you are interested in contributing to the Academy's professional development program, please specify the types of activities you would like to engage in (eg. delivering of workshops, mentoring):

Please indicate if you would be interested in sharing your clinical education experience by sharing your stories and anecdotes, to be used as a resource for the Academy and its members:

Yes
No
Maybe

Please leave any additional information that you would like us to know in the space provided below.