MEMBERS APPLICATION FORM | Faddishbuilder

Caribbean College of Family Physicians – Jamaica Chapter (CCFPJC)

New Member Application Form

Welcome!

Thank you for your interest in joining the Caribbean College of Family Physicians – Jamaica Chapter (CCFPJC).

Please complete this form to apply for membership. All information will be kept confidential and used solely for membership administration. New members apply through https://caribgp.org/membership-application-form/

PERSONAL INFORMATION

Full Name

Email Address

Phone Number

CONTACT ADDRESS

Street Address

City

State / Province

Country

PROFESSIONAL QUALIFICATIONS

Qualifications (e.g. MBBS, MD, DM, RN, etc.)

Institution(s)

Year of Qualification:

MCJ Registration Number:

PRACTICE INFORMATION

Involvement in General / Family Practice

Full-Time Part-Time

Current Position / Occupation

Parish of Practice

INTERESTS

Medical Interests

Non-Medical Interests

MEMBER PARTICIPATION & SERVICE

In what areas would you be willing to serve as a CCFPJC member? (Select all that apply)

MEMBERSHIP CATEGORY & FEES

Please select your membership category below.

(Some categories require direct application to the CCFP Secretariat.)

MEMBERSHIP CATEGORIES

ACTIVE CHAPTER MEMBER

Registration Fee: US$100
Renewal Fee: J$6,500

RETIRED & HONORARY MEMBERS

(Must apply directly to CCFP Secretariat)

Registration Fee: Free
Renewal Fee: Free

SEMI-RETIRED MEMBERS)

Registration Fee: US$100
Renewal Fee: J$4,500

ASSOCIATE MEMBER

(Interns & Residents in Family Medicine – 4-year limit; apply via Secretariat)

Registration Fee: US$100
Renewal Fee: J$4,000

STUDENT MEMBER (UP TO INTERNSHIP)

(Medical Students – apply via Secretariat; proof of student status required)

Registration Fee: Free
Renewal Fee: Free

SUSTAINING MEMBER

(Health professionals allied to medicine – apply via Secretariat)

Registration Fee: US$100
Renewal Fee: J$4,500

SPECIALIST / CONSULTANT (Non-Family Medicine)

Registration Fee: US$100
Renewal Fee: J$6,500

CORPORATE MEMBER

Please contact the CCFP Secretariat for details

PAYMENT DETAILS

💳 Payment Required

This application will only be processed after payment is received.

Select Payment Option

Option 1 Option 2

(Payment instructions will be provided after selection.)

DECLARATION

I confirm that the information provided in this application is accurate and complete to the best of my knowledge.

For Assistance

If you require clarification or belong to a category that requires direct application, please contact the CCFP Secretariat.