BSA Membership Form

* Membership Type

Please note: Group Membership Prices are subject to VAT being added at the current rate

* Payment by:

Credit / Debit Card Payments Pay by Visa, MasterCard, Maestro credit / debit cards (processed by Stripe) Direct Debits (payment instructions will follow, once application is submitted)

* Title

* First & Last Name

Initials

* Choose a Password

must be 6 or more characters

* Confirm Your Password

* Your E-Mail Address

a confirmation email will be sent to you at this address

Please note your email address will be held as your primary contact and will be displayed on membership list. Students please use personal email and not University or NHS email.

Mailing Address

* Mailing Address 1

Mailing Address 2

* Mailing City

* Mailing County / State / Region

* Mailing Country

* Mailing Postcode

* Phone Number

* Mobile Number

* Job Type

* Organisation Name

* Type of Organisation

Other type of Organisation

* Job Title

Work Department

Work Address Line 1

Work Address Line 2

Work Address Line 3

Work Address Town/City

Work Address County

Work Address Country

Work Address Postcode

Work Telephone Number

Work Telephone Number extension

I agree to my details displayed on membership list

Yes

* Why do you want to be a member of BSA

Please include a short personal statement supporting your application explaining why you want to become a member of the BSA. (200 words)

I consent to receive BSA emails

I consent to receiving emails from the BSA relating to non-BSA meetings, career opportunities and other advertising relating to audiology.

Yes
No

Be informed about non-BSA events?

Do you wish to be informed of non-BSA meetings arranged by other organisations and/or other documents relating to Audiology?

Yes
No

Special Interest Groups

Are you interested in becoming a member of any of the following special interest group?(please tick any of interest):

Adult Rehabilitation Interest Group
Auditory Processing Disorder Special Interest Group
Balance Interest Group
Cognition and Hearing Special Interest Group
Electrophysiology Special Interest Group
Paediatric Audiology Interest Group
Tinnitus and Hyperacusis Special Interest Group
Bone Conduction & Middle Ear Devices Special Interest Group

I give permission for my contact details to be shared with the relevant Chair(s) of Special Interest Group(s) I have indicated an interest in

Global Outreach

Are you interested in hearing about Global Outreach and therefore being contacted by the Global Outreach Trustee?

Gender

Self-describe Your Gender

Ethnicity

White

Asian/Asian British

Mixed/Multiple ethnic background

Black/African/Caribbean/Black British

Other Ethnic Background

(please specify where other above)

* Full Membership (Reduced Rate) Status

* Affiliated Organisation

Please provide the name of the other recognised professional body/learned society which you are a member of

* Affiliated Organisation Renewal Date

• Please provide the renewal date for your membership to the other professional body/learned society which you are a member of

Promotional code

Referred by

Please confirm who referred you

* Code of Conduct

I can confirm that I am of good character and I agree to abide by the BSA’s Code of Conduct

The code of Conduct can be found by clicking here.

This next section is for Student Membership and Early Careers Membership only
Course dates must be completed to avoid delay in application being approved

* Institute/College

Institute/College Address

* Course Title

* Date Course Commenced

*mandatory for student applicants

* Date Course Ended

*mandatory for student applicants

* Name of Course Tutor

*mandatory for student applicants

* Course Tutor Email

*mandatory for student applicants

Anti Spam

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