Membership Registration - Professionals
M indicates mandatory (required) fields
Name: M
Job Title: M
Address: M
Postcode:  Country:
Telephone:
e-mail: M
Please check your email address, if it is wrong we will not be able to contact you!
How did you hear about the Group?
Do you intend to join the
PDA Contact Group Forum Board?		 Yes No
Already joined: User name
This registration will entitle you to access the private Professional Members forums
Do you consent to your contact details being given to other professionals members? Yes No
Survey
The information requested here will help build up a picture of the services available
to children and adolescents with PDA and their families.
Discipline
Health
Paediatrician
Psychiatrist
Clinical Psychologist
General Practitioner
Speech Therapist
Occupational Therapist
Other Therapist (specify below) 		Education
Head Teacher
Deputy or Department Head
SENCO
Teacher
Learning Support Assistant

Education Officer
Educational Psychologist 		Social Services
Senior Social Worker
Social Worker
Family Aid
Academic & Research
Professor or Lecturer
Student or Post-Graduate
Researcher
Other (please specify):
Workplace
Name & Address of workplace
(if different from above):
Postcode:
Telephone:
e-mail:
Interest in PDA
What is your interest in PDA?:
Are you diagnosing PDA? Yes No
If so, are you able to take referrals? Yes No
If taking referrals, what geographical
areas do you cover, and how do you
take them?
Please confirm your e-mail address: M

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A confirmation email will also be sent to the address you have provided.
In the event of problems, please email the webmaster direct at the address shown on the initial welcome page.
The PDA membership secretary is a data controller under the Data Protection Act 1998.
The personal data you provide in this membership form will be used for membership administration and for statistical
and other purposes connected with the PDA Contact Group. Return of this form will be taken as your consent to such use.
Membership details are not disclosed to third parties for marketing or other purposes not connected to PDA.