Members Registration Form
Personal Information

If you already have the profile as a member, please do not register again. Please log in to your profile. Then you will be able to select the membership fee.

*Fields in bold are mandatory. The registration form cannot be submitted without completing these fields

Title before the name
Firstname*
Surname*
Title after the name
Email*
This email address will be used for logging in to your profile. It will be also used as the primary email address for further communication.
Gender*
Date of Birth*
Personal Address
Phone number
Please add also the area code. Use the format +420, +421 etc.
Street and House number*
City*
ZIP Code*
Country*
Low-Income Countries
Request for Reduced fee (Low-income countries)
Members from Low-income countries can ask for a reduced membership fee. ESPA Secretariat will assess the request within a few days after the submission. You will be informed by email. After that, you will be able to select your membership fee.
Professional Details
Institution/Hospital*
National Society*
(if non aplicable, please enter N/A)
I am interested in the individual ESAIC membership*
ESAIC membership*
I give permission to share my personal data with the ESAIC Secretariat to obtain the individual ESAIC membership
Professional Address
Street and House number
City
ZIP Code
Country
Consents
Consent to Personal Data Processing*
For more details click HERE
Consent to Receiving Newsletters/Mailing*
For more details click HERE