Application Form

I wish to apply for membership of the WA Occupational Therapy Association Inc 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 WA Occupational Therapy Association website in 2017 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 2017. Please note that a copy of your qualifications should be emailed to info@waota.com.au or faxed to (08) 9388 1492.

Membership Category and Prices for 2017:- Click here

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.

Early Bird payments must be paid in full

Standard Rate applies after 27th January 2017

Payment Type Standard Fee payments can be paid in instalments.
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 no
Name of Practice
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 WA Occupational Therapy Association (formerly OT AUSTRALIA WA) Memorandum & Articles of Association and OT AUSTRALIA Code of Ethics.

Privacy Statement

The WA Occupational Therapy Association 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 the WA Occupational Therapy Association databases and distribute WA Occupation Therapy Association 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 the WA Occupational Therapy Association 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.