Requesting a 911�� Representative

If you would like 911��'s help to find a representative from the neonatal community to join a working group or committee please provide details in the form below. Please note that we do receive quite a lot of these requests and due to the timing of our monthly newsletter it may take 6-7 weeks for us to share the request and review responses. If you have any questions or would like to send over a term of reference document to accompany this form please contact the 911�� Office, however we are only able to process requests once we have received all of the information contained in the form.

External Representative

Select your organisation if there is a match.

Name of working group or committee

Name of chair of the group / committee (if known) (optional)

Purpose of the group / committee

What will the representative be expected to do? (Attend meetings, write or review documents etc.)

Are you looking for someone to specifically represent 911��?

If the person will be representing themselves please provide a name and email for interested parties to contact (optional)

Do you know of any 911�� members already on the group? If yes please provide details. (optional)

Will the group produce a document that you will wish 911�� to endorse?

Expected Duration of Commitment

Meeting Frequency

Please provide dates of any meetings already scheduled. (optional)

Who can volunteer for this group (consultant, resident doctor, nurse, allied health professional, service user etc.)? If all can apply please write 'any 911�� member.'

Is this a paid or voluntary position?

Will expenses be covered?

Additional information (optional)

Communication preferences

If you are a human, ignore this field

911������