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Username
(Required)
Email
(Required)
Salutation
(Required)
Choose
Mr
Mrs
Ms.
Mx.
Dr.
Prof.
Prefer not to answer
Name
(Required)
First Name
Last Name
City/Town
(Required)
Country
(Required)
Street Address
Postal Code
(Required)
Profession
(Required)
Choose…
Dietician
Educator
Licensed or Registered Practical Nurse (LPN/RPN)
Nurse
Nurse Practitioner (NP)
Occupational Therapist
Other
Paramedic
Pharmacist
Physician
Physician – College of Family Physicians of Canada
Physician – Royal College of Physicians and Surgeons
Physician Assistant
Physiotherapist
Professor
Psychologist
Recreational Therapist
Registered Nurse (RN)
Registered Psychiatric Nurse (RPN)
Researcher
Resident
Respiratory Therapist
Social Worker
Spiritual Care
Student
Support Worker/Aid/Attendant
Profession Other
(Required)
Discipline
(Required)
Choose…
Cardiology
Community Health
Complex Continuing Care
Critical care
Emergency medicine
Family medicine/ General practitioner/ Primary care provider
Gastroenterology
Geriatrics
Hematology
Internal medicine
Medical oncology
Nephrology
Neurology
Other
Palliative care
Pediatrics
Psychiatry
Public Health
Pulmonology
Radiation oncology
Rehabilitation/Physiatry
Surgery
Discipline Other
(Required)
Gender
(Required)
Choose…
Man
Woman
nonbinary
Prefer not to Answer
Racial Identity
(Required)
In our society, people are often described by their race or racial background. These are not based in science, but our race influences the way we are treated by individuals and institutions, and affects our health. Which category(ies) best describes you? Select all that apply.
Black
Eastern Asian
Indigenous (First Nations, Inuk/Inuit, Métis)
Latin American
Middle Eastern
South Asian
Southeast Asian
White
Another racial category
Do not know
Prefer not to answer
Black Identity
(Required)
Black African
Black Canadian
Black Caribbean
African American
Afro Indigenous
Indigenous identity
(Required)
First Nations
Inuk/Inuit
Métis
Do not know
Prefer not to answer
Another racial category
(Required)
Organization
Phone Number
Languages spoken
Choose…
English
French
English and French
Other
Pricing
(Required)
Individual rate – $350.00
Community-based – general – $250.00
Community-based – Black-led / Black-serving – $150.00
Individual student / resident rate – $150.00
Coupon Code
Coupon Code
(Required)
Validate Coupon
Total
Credit Card
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Comments
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