New Member Registration FormPlease DO NOT use this form for the RENEWAL of existing membership

Please note – all fields are required (must be filled in) unless otherwise indicated.
Please hover over the ? (question mark) to read more about what to enter in the field.

Please do not attempt to complete this form with any mobile device that has a screen resolution of less than 960 pixels wide e.g. older Iphones and Android smart phones.

  Personal Information  
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?
  Personal Contact Details  
  Personal Postal Address  
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?
  Professional  
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?
?
  Education and Qualifications  
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?
  Intern Supervision  
  Malpractice Insurance and Fees Payment Method  
?
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  Create or Edit your Practice Details  
  General  
  Practice Contact Details  
  The address of the practice i.e. how a client will find you  
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  PRACTICE OWNER ONLY - Practice Accreditation Details  
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  PRACTICE OWNER ONLY - Virgin Active Details  
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  Annual Member Survey - Internet Usage, Communications & Feedback   

Your feedback during is incredibly valuable in identifying and defining our overall approach to future services and member communications. We ask that you take just a few minutes to complete this survey. Thank you for helping us to add value to your membership.

  Internet  
  What equipment do you USUALLY use when surfing WEB SITES? (Select all that apply)    Desktop or Laptop Computer 
Apple iOS System
 Tablet - with a Touch screen which is at least 8" WIDE or more 
iPad Tablet
Android Tablet
MS Windows Tablet
 Smartphones or mobile device - screen SMALLER than 6" wide 
iPhone
Blackberry
Android e.g. Samsung, HTC, Motorola
Windows phone
  What type of Internet Connection do you PRIMARILY use?  
  Do you use your CELL PHONE to answer emails and manage your mail inbox?  
  Which browser do you primarily use when surfing websites?  
  Do you ALWAYS HAVE TO share a computer, with other BASA MEMBERS, to access the BASA website and Learning Centre?  
  How often do you use the following social media networks?  
Social Media Daily Weekly Never
Facebook
Twitter
Google+
LinkedIn
  BASA Communications  
  What time of the day do you USUALLY read your PERSONAL emails e.g. Newsletters from BASA?  
  How do you want to receive communications from BASA?  
  Contacting BASA with a question  

If you want to ask BASA a question about something, would you rather use an Online Chat service via the Basa website (response from a live person) OR would you prefer to send an email to BASA OR phone BASA (landline or cell)

  If BASA were to provide an exclusive online Member Community Hub with special interest groups, regional groups, discussion forums and chat activity streams (just like Facebook but private to BASA members only), would this be something that you think you would use regularly to communicate and interact with other Bio’s on different topics?  
  Please tell us what you think ...  
  Agreement of Terms and Conditions  
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P O Box 12448, Clubview 0014, Pretoria
Gauteng, South Africa
Registration: 107-094-NPO
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