Student Application Form

This form is for pharmacy and pharmacy technician students (or equivalent) enrolled in a first professional degree or diploma program.

FREE membership for students during the first year of their program!

Afterwards, Students pay an annual fee of $65 plus tax.
NL members pay an additional $5 in branch fees.
Personal Information
Full Name*

PrefixFirst NameMiddle NameLast Name
Preferred Name
Pronouns

He/HimShe/HerThey/ThemOther
Birth Date

YearMonthDay
Primary E-mail*
For CSHP correspondence
Alternate E-mail*
To be used if you cannot be reached at your primary e-mail
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Would you describe yourself as part of an equity-deserving group?

L2SGBTQ+First Nations, Inuit, Métis or other Indigenous groupBlack or Person of ColourPerson with a disabilityWomanNoOther
Do you self-identify as an Indigenous (First Nations, Métis, Inuit) person?

YesNoDecline to answer
If someone referred you to CSHP, provide their name in this field
Education
School*
Program
Degree or diploma*
Which degree(s) or diploma(s) will you earn at the end of your program?
In which program year are you registered?*
Graduating year (or expected)*
Please provide verification of enrollment in your program (ex: copy of your student card or letter of acceptance).

Cancelof
Fees

For the July 1, 2024 to June 30, 2025 cycle.

Fees will be waived for students in their first year of pharmacy school.

Your fee will be determined according to the branch that you choose from the list below:

Branch and Chapter Selection
Select your branch*
Your branch should match your province of residence. Residents of the Yukon Territory, Northwest Territories or Nunavut may select any CSHP branch.
Select your chapter
British Columbia and Ontario only. Chapter selection is complimentary.
Acknowledgement
I wish to join CSHP, and I understand that I will be invoiced for the cost of my membership if I am in my second, third, fourth, or fifth year of pharmacy school.*

Yes
I would like to receive CSHP news to my email inbox*

YesNo
Please verify that you are human*
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Personal Information