Enrollment Form for Participants (Healthcare Delivery Organizations)

We are inviting healthcare organizations across Canada to enroll as PARTICIPANTS in the Safer Healthcare Now! Campaign.

Enrollment in the Campaign is a simple two stage process:
(1) Complete the form below, then click Save
(2) Print your enrollment form, obtain a signature from your CEO/Designate, and fax to the number provided.

Fields marked with a * are required

Enrollee Organization


Please note that the information below will be posted "as entered".  Please double-check your information for accuracy and include the full organization name (acronyms can be entered in brackets before or after the full name if preferred)   

Is your Organization a health region/district/authority?
Organization Name*  
Organization Address*  
Organization Address 2
Organization City*  
Organization Province/Territory*  
Organization Postal Code*    

CEO Information

Salutation*
CEO First Name*
CEO Last Name*
CEO Title*  
Address same as organization address above
CEO Address*  
CEO Address 2
CEO City*  
CEO Province/Territory*  
CEO Postal Code*    
CEO Email*    

Please Re-enter Email*

  
CEO Phone
(xxx-xxx-xxxx)*		   Ext:
CEO Fax
(xxx-xxx-xxxx)*		  
 

Designate for CEO Information

Salutation
Designate First Name
Designate Last Name
Designate Title
Address same as organization address above
Designate Address
Designate Address 2
Designate City