PCRS are committed to helping you make sure your group runs effectively and we have a range of tools and resources that can not only help you get started, but will help you to sustain your group into the future. This for form to be completed by the appointed lead of the group. Group leader First Name * Last Name * Email * Region * - Select -East MidlandsEast of EnglandGreater LondonNorth EastNorth WestSouth CentralSouth EastSouth WestWest MidlandsYorkshire & HumberNorthern IrelandScotlandWalesInternational Professional Status * - Select -GPRespiratory Specialist DoctorIntegrated Care PhysicianOther Qualified DoctorPractice NurseNurse Practitioner (General Practice)Respiratory Nurse SpecialistOther Qualified NursePharmacistRespiratory Specialist PhysiotherapistOther supervised clinical role (eg healthcare assistant, emergency care practitioner, physician assistant)Other qualified health professionalNon-clinician (eg researcher, commissioner, manager)Pharmaceutical or device company or agency thereofRetired GP, nurse, other qualified health professional Nature of Role GP trainer GP Partner GP / Clinical Commissioner Researcher Practice respiratory lead Respiratory service(s) team lead / manager CCG / MCN / Locality respiratory lead None of the above Setting in which you work GP practice Community team Hospital based team CCG / Health board University academic department Other not for profit organisation Commercial company None of the above Your Peer Support Network Group Profile Group Name * Group Status * - Select -ActiveInactiveFolded Group composition * - Select -Nurses onlyMulti-disciplinaryOther - please specify Please specify Group focus * - Select -Respiratory group focusing specifically on respiratory issuesProfessional group focusing on issues related to the professional role (e.g. practice nurse group)Other - please specify Please specify Group purpose Provision of education and updates through regular meetings Professional updates Sharing best practice Networking Service development / delivery Research Description of the group for inclusion on PCRS website* * Region * - Select -East MidlandsEast of EnglandGreater LondonNorth EastNorth WestSouth CentralSouth EastSouth WestWest MidlandsYorkshire & HumberNorthern IrelandScotlandWalesInternational Nature of the group information provided will be used by PCRS to understand the needs of its groups and/or monitoring purposes Group Address Address line 1 * Address line 2 City * Postal Code * Country * United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic Of TheCongo, The Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicCôte d’IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands County * - None - Terms of affiliation Terms of affiliation PCRS agrees, subject to the conditions stated to: Provide the Lead with membership to the PCRS free of charge for the duration of the Group’s affiliation For Leads who are not already members of PCRS, free membership will be provided from the date of affiliation Leads who are already members will be provided with free membership from the date their paid membership expires. No refunds of membership fees will be given Keep the Lead, through his/her membership of PCRS, up to date of PCRS activities and provide him/her with suggestions for local group activities and meetings through regular affiliated groups newsletters Permit the Group to use and promote resources and materials from the PCRS website including specific local group, resources such as the resource pack with example agendas, invite letters, event briefs attendance certificates Invite, subject to available funding, the Lead to an annual meeting for the leads of its affiliated groups in order to share ideas across the groups and to support the professional development of the group leaders Promote the activities of the Group by sending out an email on behalf of the Group to PCRS members in the relevant geographical area or if appropriate via an article in Primary Care Respiratory Update Leads should contact info@pcrs-uk.org to take advantage of this opportunity. The Group may state that it is affiliated to the PCRS in its materials and may use the “PCRS” logo in this context, provided it is used in accordance with the approved template. A copy of the PCRS logo can be obtained from info@pcrs-uk.org 7. Group website listing Details of the Group will be included on the PCRS website* and individuals will be able to contact myself as the Lead via the PCRS members directory. 8. Sharing Group Lead data PCRS may forward my name and email as the Lead of the Group onto the pharmaceutical companies providing funding for the PCRS affiliated groups programme 9. The Group will Respect and uphold the aims, principles and purposes of PCRS at all times Q9b The group will Only use the PCRS name and logo in accordance with point 6 above Q9c The group will Under no circumstances use PCRS's name or logo in any way that suggests its activities are endorsed by PCRS 10. I have read and agree to the following terms The parties are independent entities and nothing in these terms of affiliation shall be construed to establish a partnership, joint venture, agency or similar relationship between them. PCRS has no financial or legal responsibility for the group Q10b I have read and agree to the following terms Either party may terminate this agreement license by giving one months’ notice to the other party Q10c I have read and agree to the following terms Affiliation will be terminated by PCRS if the Group breaches any the terms of this affiliation agreement or does not complete the annual form Q10d I have read and agree to the following terms PCRS reserves the right to terminate this agreement if the Group is inactive (i.e. no events or activities) for 12 months 11. As group lead I will Complete the annual feedback form (see https://pcrs-uk.org/form/affiliated-group-leader-annual-return) to update the details of the Group and to confirm the number of members, events and other activities in the previous year Q11b As group lead I will Notify info@pcrs-uk.org if the Lead changes Group Leader eSignature * Sign above Leave this field blank