MEDICAL REGISTRATION NUMBER *

DATE *

(M/D/Y)

LAST NAME *

FIRST NAME *

MIDDLE NAME *

DATE OF BIRTH *

MAILING ADDRESS *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

EMAIL ADDRESS *

PHONE *

WORK *

HOME

FAX

PAGER

CELL

 DEGREES, DIPLOMAS ETC.

Qualifications *

Institution *

Year *

CURRENT POSITION/ OCCUPATION *

INVOLVEMENT IN FAMILY PRACTICE: *

• PART TIME
• FULL TIME

 INTERESTS

Medical Interests *

Non-Medical Interests *

In what area can you serve as a member of the College *

• Production of CME Activities
• Primary Care Research
• Advocacy
• Membership & Mentorship
• Fund Raising/Finance
• Other

MEMBERSHIP FEE US$80.00 *

NAME OF REFERRING CCFP MEMBER: *

REFEREE INFORMATION (NOT APPLICABLE TO FOUNDING MEMBERS)

ADDRESS *

PHONE *

YOUR CV’s *

Click or drag a file to this area to upload.

(A copy of your CV’s would be appreciated; also an indication of your willingness to assist with the development of the College and in what aspect.) Copy to 19A Windsor Avenue, Kingston 5, Jamaica, West Indies

Your Degrees/Certificate *

Click or drag a file to this area to upload.

Your Practicing Certificate *

Click or drag a file to this area to upload.

Your Passport size Photograph *

Click or drag a file to this area to upload.

Please Upload Your Receipt *

Click or drag a file to this area to upload.

Payment Agreement *

• I've made the payment

Once payment is completed, please accept the payment agreement to continue.

Submit

INVITATION FOR MEMBERSHIP 

YOU ARE HERBY INVITED TO BECOME A MEMBER OF THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS

• WE ARE A PAN-CARIBBEAN ORGANIZATION WHOSE MISSION, VISION, VALUES AND OBJECTIVES ARE TO PROVIDE THE HIGHEST STANDARD OF CARE FOR OUR CARIBBEAN PEOPLE BY A TEAM OF WELL TRAINED, HIGHLY MOTIVATED AND COMMITTED DOCTORS.

• WE OFFER HIGH QUALITY CME COURSES THROUGH WELLS STRUCTURED AND PEER REVIEWD WORKSHOPS AND SEMINAR EACH MONTHS.

•  OUR MONTHLY UWIDEC LECTURES OFFERS YOU SPECIAL OPPORTUNITIES TO SHARE YOUR EXPERIENCE, PRESENT ORIGINAL RESEARCH PAPERS, DISCUSS ISSUES AND INTERACT WITH YOUR COLLEAGUES FROM AROUND THE CARIBBEAN.

• AS A MEMBER OF OUR TEAM, YOU WILL BECOME AN IMPORTANT PARTICIPANT IN OUR CARIBBEAN FAMILY PHYSICIAN KNOWLEDGE NETWORK (CFPKN). A GROUP OF DOCTORS ACTIVITY INVOLVED IN OFFICE BASED-RESEARCH.

• OUR COMMUNITY OUTREACH AND VOLUNTEERISM PROGRAM OFFER YOU AN EXCELLENT OPPORTUNITY TO INTERACT WITH NGO’s, CHARITABLE ORGANIZATIONS AND SMALL INTEREST GROUPS AND LEND A HELPING HAND BY PROVIDING QUALITY PRIMARY CARE TO HOMELESS AND SOCIALLY EXCUDED POPULATIONS.

• HE COLLEGE LIAISES INTIMIMATELY WITH THE FACULTY OF MEDICAL SCIENCE (UWI) AND OFFERS YOU AN OPPORTUNITY TO TEACH, DESIGN CME COURSES DEVELOP PRACTICE GUIDELINES FOR PATIENT MANAGEMENT, CREATE GP’s FOMULARITIES, AND BECOME A MENTOR FOR UNDERGRAD AND POSTGRAD MEDICAL STUDENTS.

• JOIN US AND BECOME AN ADVOCATE FOR CHANGE, AND HELP TO INFULENCE HEALTH CARE PLOICIES THROUGHOUT THE CARIBBEAN.