Application Form

I wish to apply for membership of the Australian Association of Occupational Therapists WA (Inc) in Western Australia and I agree to accept and abide by the ethics and constitution. If you do not agree to having your work details published on the OT AUSTRALIA WA website in 2012 you must advise the Association office.

Personal Details

Title
Surname
First Name
Previous Name
Postal Address
Suburb
Post Code
Phone (Home)
Mobile
Fax
Email
Date of Birth Year

Membership Details

Please indicate your membership category for 2012. Please note that a copy of your qualifications should be emailed to info@otauswa.com.au or faxed to (08) 9388 1492.

Membership Category and Prices for 2012:- click here to view

Qualifications Provided
Membership Category
Students

Payment Details

Membership is for the calendar year, January to December and cannot be cancelled during the year. As a service for those paying by CREDIT CARD a quarterly payment option is provided. By submitting this secure form you have agreed to continue payments for the entire year.

Payment Type

*Please note: Early Bird payments must be paid in full by 13 January 2012 and 25 February 2012 for students (installment plan not available). Early Bird payment discounts for 2012 will NOT be available after these dates. Standard Fee payments can be paid in installments.
Payment Method

*Please note: there is a $10 Administration fee attached to quarterly installments
Credit Card Number
Credit Card Type
Credit Card Expiry Month

Year
Credit Card Holder Name
TOTAL COST

Membership Update

Work Details

Organisation
Department
Position Held
Address
Suburb
Postcode
Phone
Mobile
Fax
Email
Website
Work Category
Work Sector
Work Setting Hospital

Acute Hospital Inpatient

Acute Hospital Outpatient/Ambulatory

Sub-Acute Hospital Rehab Inpatient

Sub-Acute Hospital Outpatient/Ambulatory Community

Community Health Service

Community Mental Health

Day Care Centre

Disabilty Services (DCS, SC, MS, PDSS)

Domiciliary Care Services

Residential/Retirement Living/Accommodation Services

Vocational Rehabilitation/Injury Prevention(Non-hospital/Industry)Private Practice

Private Practice Rooms

Private Practice – Home Based Education

Pre-School Education Services

School Education Services

Tertiary Education Services

Community Education Industry

Industry/Business Sector Other

Other Government (policy, non-clinical)

Other

None
Client Age 0-17yrs (Child and Adolescent)

18+yrs (Adult)

18-65yrs (Adult of Work Age)

65+yrs (Older Adults)

All Ages

Not Applicable (no clients)
Private Practice

‘Find an OT’ Website Entry for Private Practitioners Only

Website Directory Listing Desired (‘Find an OT’)

yes

noName of Practice

A copy of WRITTEN CONFIRMATION of Approval of Business name from the OT Registration Board WA is to be received by OT AUSTRALIA WA office BEFORE your details can be entered onto the websiteName of Occupational Therapist

Address and contact details to use for website entry only. Indicate whether the same as 1 (work details) or as below

Address    
Suburb Post Code
Phone Email
Mobile Website
Fax    

Please tick ALL relevant categories below

Services

Rooms Nursing Home Visits
Home Visits School / Day Care Visits
Hospital Mobile Only Service

Approved Provider

Registered for Medicare APSP (Approved Autism Panel Service Provider
Better Access to Mental Health ASD (Autism Spectrum Disorder)
EPC (Enhanced Primary Care) HICAPS/eclaiming
PDD (Pervasive Developmental Disorder) DVA (Department of Veterans’ Affairs)
FPS (Focused Psychological Strategies)    

Client Group

Workers Compensation Privately Insured
Motor Vehicle Accident    

Client Age Group

Babies Older Adults
Children All
Adolescents N/A
Adults

Additional Work Details

Organisation
Department
Position Held
Address
Suburb
Postcode
Phone
Fax
Email
Website

Qualifications

OT Registration Board No
Original date of registration  
   
University  
Qualification Type Date of Qualification Institution

Expertise

Area of expertise (Please select up to 5 areas)
  Key Expertise   Key Expertise
AC Access LY Lymphoedema Management
AG Aged Care MA Manutention
AL Alzheimers MG Management
AM Acute Medicine MH Mental Health
AMPS Assessment of Motor & Process Skills ML Medico-Legal
AP Acute Psychiatry NE Neurosciences
AT ACAT (Aged Care Assessment Team) NU Neurology
BU Burns OH Occupational Health & Safety
CA Cardiac ON Oncology
CD Community Development OP Orthopaedics
CE Cerebrovascular PA Palliative Care
CO Counselling PC Primary Care
CP Cerebral Palsy PE Paediatric
CS Child Psychiatry PG Psychogeriatrics
DD Developmental Delay PH Public Health
DI Disability PM Pain Management
DP Disability Physical PR Psychosocial Rehabilitation
DR Driving Assesment and Rehabilitation PS Psychiatric Rehabilitation
ED Education PW Project Work
ER Ergonomics PY Psychiatry
ET Ethics RE Physical Rehabilitation
EQ Equipment RH Research
GE Gerontology RU Rheumatology
GM General Medicine RP Rural Practice
GS General Surgical SE Seating
HA Hand and Upper Limb SI Sensory Integration
HD Head Injuries SM Stress Management
HM Home Modifications SP Splinting
HP Health Promotion ST Soft Tissue Therapy
HV Home Assessment/Visiting VI Visual Impairment
IM Injury Management Prevention VO Volunteers
LD Learning Disability VR Vocational Rehabilitation
Current Interest Group Membership
   
   

I certify that all information furnished in this document is true and accurate in every respect.

I certify that I have not been refused membership of any Occupational Therapy Association, nor registration, in Australia or overseas.

I agree to abide by the OT AUSTRALIA WA Memorandum & Articles of Association and OT AUSTRALIA Code of Ethics.

Privacy Statement

OT AUSTRALIA WA is committed to supporting the National Privacy Principles. We will only collect and store information about you that is necessary. The information you provide may be used to offer, provide and improve our services to you and may also be disclosed to other parties such as organisations contracted to operate and maintain OT AUSTRALIA WA databases and distribute
OT AUSTRALIA WA information.

We will not otherwise, without your consent, use or disclose the information you provide for any other purposes unless it would reasonably be expected that such a purpose is related to the offer, provision and improvement of OT AUSTRALIA WA services and benefits to you or where such purpose is permitted or required by law.

You are entitled to request reasonable access to the information we hold about you.