Help us build support for Safer Healthcare Now!

We are inviting the enrollment of professional and regulatory bodies, associations, health ministries, health organizations or other such groups as PARTNERS in the Canadian 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

By Enrolling as a PARTNER please indicate how your organization can offer help:
Promote enrollment
Sponsor education sessions or other Campaign activities
Spread information through our membership

To officially enroll your organization as a Partner in the Safer Healthcare Now! Campaign, please complete the following.

Organization Name*
Organization Address*
Organization City*
Organization Province/Territory*
Organization Postal Code*
CEO First Name*
CEO Last Name*
CEO Title*
CEO Email*
Our key contact as PARTNER will be:
Contact First Name*
Contact Last Name*
Contact Email*
Contact Phone (xxx-xxx-xxxx)*	Ext:
Contact Fax (xxx-xxx-xxxx)*
Using the Key Organizational Contact’s email address entered above, and the password entered below, you can log into our site in the future to update the information collected on this form. Please choose a password of at least 6 characters in length, and enter it in the space below. Password*     Confirm Password

Can we name your organization as a Campaign partner on www.saferhealthcarenow.ca and in Campaign marketing materials?*
Yes No