MEMBERSHIP APPLICATION/RENEWAL FORM
Should there be insufficient room for any answer, please attach a further sheet, indicating the section letter.
PLEASE COMPLETE PERSONAL DETAILS BELOW:
Surname: / Forename: / Title:Job Title/Role:
Company Name :
Contact Address:
Post Code:
Tel:
e-mail address: / Website:
PLEASE SELECT MEMBERSHIP TYPE:
Student Membership complete following questions and go to section 9
Profession you are studying......
......
Date your course will be completed......
A Are you a professional organisation with an interest in case management (but not a case management company or employee of a case management company) such as solicitors practice or nursing/care agency?
Yes. Please complete Section 1
No. Please go to B
Section 1 - Corporate MemberNew Corporate Member / Corporate Renewal
As a corporate member you can have up to 3 additional members . Please complete their details below, if applicable.
Surname: / Forename : / Title:
Job Title/Role:
Surname: / Forename : / Title:
Job Title/Role:
Surname: / Forename : / Title:
Job Title/Role:
NOW GO TO SECTION 9
B Are you a practising case manager? For clarification as the title can be ambiguous: this does not include those who work for care agencies and arrange care nor those working in residential care – rather they should join as affiliates if they are not under a corporate membership
Yes. Please go to C
No. Please complete Section 2.
Section - 2 Affiliate
New Affiliate Member Affiliate Renewal
NOW GO TO SECTION 9
C Do you hold a registered qualification as listed below?
Chartered Psychologist Physiotherapist
Medical Doctor Social Worker
Registered Nurse Speech & Language Therapist
Occupational Therapist
Yes. Please tick your qualification in above list and then go to D
No. Please complete Section 5
D Have you completed a successful peer review and been awarded advanced status?
Yes. Please complete Section 3
No. Please complete Section 4
Section 3 - Advanced Registered Practitioner
Advanced Registered Practitioner Renewal
I confirm I adhere to the BABICM standards and competencies at level 2
and 3 within my case management practice. I understand that to retain my advanced membership I need to update my knowledge every year, and that I must make myself available to volunteer to assist the paid reviewers with the peer review process.
Advanced Registered Practitioners who progress to managing other case managers and who do not actively manage their own case load will also retain their membership status.
NOW COMPLETE SECTION 6
Section 4 - Registered Practitioner
Registered Practitioner New Renewal
I confirm I adhere to the BABICM standards and competencies at Levels 1 and 2 within my case management practice. I understand that membership in this category is on a temporary basis for the length of time required to prepare for peer review for admission to the Advanced Registered Practitioner Category
NOW COMPLETE SECTION 6
Section 5 - Practitioner
Practitioner New Renewal
I confirm I adhere to the BABICM standards and competencies at Levels 1 and 2 within my case management practice.
NOW GO TO SECTION 7
Section 6 - PIN numbers
New
Renewal
Membership of Professional Bodies and PIN number for each:……………..
......
......
NOW PLEASE GO TO SECTION 7
Section 7 – Employment details:
Sole practitioner Case Management Company
Private healthcare organisation Social services
NHS/ Statutory Insurance company
Private Rehabilitation unit Voluntary organisation
Other, please specify:
…………………………………………………………………………………………….
Company Name …………………………………………………………………….
Are you responsible for employment and/or management of other case managers? Yes/ No
NOW GO TO SECTION 8
Section 8 - Experience
1. What date did you commence active brain injury case
management practice? ......
2. What languages do you speak fluently other than English? ......
......
NOW GO TO SECTION 9
Section 9: Declaration
I, the undersigned, hereby apply to be classified in the above fashion by The British Association of Brain Injury Case Managers Limited.
I understand that my application is subject to consideration by the Association’s Council whose decision is final.
I agree to uphold the Principles and Guidelines for Case Management Practice, a copy of which I have retained for record purposes.
I grant permission for my membership records to be held on computer for the purposes of handling membership, publishing the members’ register and mailing out membership information.
Signature ………………………………………... Date ……………………..
(Please put electronic signature or type name)
Membership is for one year and renewal information will be sent out automatically. Annual fee is £100 for an individual membership and £300 for corporate membership.
Please make cheques payable to The British Association of Brain Injury Case Managers Limited. Do not send cash.
Payments can be made by BACS. Please email for details.
Please return this form with the subscription fee to:
BABICM Secretary, 318 Warth Business Centre,
Warth Industrial Park,
Warth Road, Bury. BL9 9TB
FOR OFFICIAL USE ONLYBank:
Chq No:
Amount:
Date of chq:
Update record:
Update web database:
Terms and Conditions of Lapsed Membership
Membership with BABICM should be continuous providing renewal is paid yearly on time. Membership cannot be put on hold for any reason. You will receive 3 reminders (one a month before renewal date and two reminders in the month of renewal). If you have not renewed a week after the expiry date then your membership will be terminated. If advance members do not renew, their details will be removed from the website.
6
Issued Jan 2017