EmailMe Form - Health Care Professional (HCP) Ambassador Sign-Up

Name *

First Last

Work Title / Role *

Please write in full, no acronyms please.

Department *

Please write in full, no acronyms please.

Organization (Name of Centre, not Health Authority) *

Please write in full, no acronyms please.
Please indicate the hospital or centre you work in – not your health authority. Thank you.

Business Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Business Email *

Business Work Number *

### - ### - ####

What is your preferred language

English

French

Both

Are you registered with any professional organizations? Please check all that apply:

College of Nurses

College of Social Work

Canadian Association of Neuroscience Nurses (CANN)

Canadian Association of Psychosocial Oncology (CAPO)

Canadian Association of Nurses of Oncology (CANO)

Royal College of Physicians and Surgeons of Canada

Other (please specify)

Please note, that for both Canadian Association of Neuroscience Nurses (CANN) and Canadian Association of Psychosocial Oncology (CAPO), Brain Tumour Foundation of Canada offers a $1500 grant to one member every year

Please provide a short bio of your work with brain tumour patients and families:

Please tell us a little more about the brain tumour population you work with and the work you do:

Most of the patients / people I work with are?

Pediatric

Adults

Both

Do you know approximately how many brain tumour patients your organization serves every year?

What is the focus of the work you do / focus of your organization?

How did you hear about the HCP Ambassador program?

Brain Tumour Foundation of Canada Website

Brain Tumour Foundation of Canada Staff Member

Colleague

Other

Please Indicate Staff Member Name:

Brain Tumour Foundation of Canada hosts many events across the country and a webinar series, are you interested in speaking / presenting in the future?

Email Signature *

Date *

MM / DD / YYYY