CCFP-YDM Membership Application Form Please enable JavaScript in your browser to complete this form.Caribbean College of Family PhysiciansYoung Doctors’ Movement (CCFP-YDM)Application for New Membership SECTION 1 — PERSONAL INFORMATION1. Full Name:2. Title: Dr.Other:3. Gender (optional):FemaleMalePrefer not to sayOther:4. Date of Birth (DD/MM/YYYY):5. Country of Residence:6. Email Address (Primary):7. Mobile/WhatsApp Number: SECTION 2 — PROFESSIONAL DETAILS8. Current Professional Status: Medical Student InternSenior House Officer (SHOFamily Medicine ResidentEarly-Career Family Physician (≤5 years)Other:9. Year of MBBS/MD Graduation:10. Current Workplace / Institution:11. Country of Practice:SECTION 3 — MEDICAL COUNCIL REGISTRATION 12. Medical Council Registration Number: (e.g., Jamaica Medical Council, Barbados Medical Council, TT Medical Board, etc.)13. Date of Initial Registration:14. Expiry Date (if applicable):SECTION 4 — CCFP-YDM MEMBERSHIP FEESMembership Fees (Select One):Student – US $50.00Intern / Senior House Officer – US $100.0015. Payment Method:Online Payment PortalBank TransferCredit/Debit CardOther:16. Upload Proof of Payment (JPG/PDF):SECTION 5 — CCFP MEMBERSHIP STATUS17. Are you a current CCFP member?YesNoI have submitted my CCFP membership applicationSECTION 6 — AREAS OF INTEREST(Select all that apply)Leadership & GovernanceEducation & TeachingResearch & PublicationsDigital Health & InnovationPlanetary HealthMental HealthNCDsDisaster PreparednessFM360 ExchangesWONCA WPs/SIGsSocial MediaConference PlanningMembershipOther:SECTION 7 — MOTIVATION STATEMENT18. Why do you want to join the CCFP-YDM?19. What skills or experience can you contribute?SECTION 8 — DECLARATION I declare that: 1. The information provided is accurate. 2. I meet the eligibility criteria for the Young Doctors’ Movement. 3. I understand that annual renewal is required on January 1. SUBMISSION By completing and submitting this form you confirm that you have read and understood the term and conditions of joining the movement. Thank you for joining the CCFP Young Doctors’ Movement! REMINDER ➡ Annual renewal is required. ➡ Renewals are due on January 1 each year• Payment Link:• Bank Transfer Details:• Reference to Use: Submit
