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ISHQ MEMBERSHIP REGISTRATION FORM
(Society for Innovation in Safety & Healthcare Quality)
Section 1: Membership Category
(Please select one)
Student Member
Professional Member
Section 2: Personal Information
1. Full Name
*
2. Email Address
*
3. Mobile Number
*
4. Gender (Optional)
Male
Female
Prefer not to say
5. Date of Birth (Optional)
6. City
*
7. State
*
8. Country
*
Section 3A: Academic Details (For Student Members Only)
1. Course / Program Enrolled
*
2. Institution / University Name
*
3. Field of Study
*
Healthcare
Nursing
Public Health
Hospital / Healthcare Management
Other:
4. Current Year of Study
*
5. Expected Year of Completion
*
6. Upload Valid Student ID
*
Accepted formats: PDF, JPG, PNG (Max 5MB)
Section 3B: Professional Details (For Professional Members Only)
1. Current Designation
*
2. Department / Function
*
Quality
Patient Safety
Nursing
Clinical Services
Operations
Risk Management
Infection Control
Administration
Other:
3. Organization / Hospital Name
*
4. Total Years of Experience
*
0–2
3–5
6–10
10+
5. Areas of Interest (Select all that apply)
Patient Safety
Healthcare Quality Improvement
Accreditation (NABH / JCI / Others)
Clinical Governance & Risk Management
Healthcare Operations
ESG & Sustainability
Digital Health & Quality Innovation
6. Upload Professional Proof / ID (Optional)
Accepted formats: PDF, JPG, PNG (Max 5MB)
Section 4: Qualifications & Certifications (Optional)
1. Highest Qualification
2. Certifications Held (if any)
NABH Assessor
CPHQ
Lean / Six Sigma
Other:
Section 5: Engagement Preferences
1. Interested in volunteering for ISHQ activities?
Yes
No
2. Interested in research and publications?
Yes
No
3. Interested in speaking / presenting at ISHQ events?
Yes
No
4. How did you hear about ISHQ?
Website
Colleague / Peer
Conference / Workshop
Social Media
Institution
Section 6: Declaration & Consent
I declare that the information provided above is true and correct.
I agree to abide by the mission, vision, and code of conduct of ISHQ.
I consent to receive official communications related to ISHQ activities, events, and resources.
Section 7: Membership Fee & Payment
Membership Category:
Student Member
Professional Member
Payment Mode:
UPI
Credit/Debit Card
Net Banking
Transaction ID / Reference No.:
Payment Receipt Uploaded / Auto-Generated
Accepted formats: PDF, JPG, PNG (Max 5MB)
Submit Registration