General Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Engagement and Priorities
Please select what you hope to gain from membership.
*
Advocacy & Representation
Training and Professional Development
Networking Opportunties
Research & Policy Updates
Webinars
Business Exposure
Annual Conference
Other
Please select activities of interest
*
Board involvement
Committees & Working Groups
Special Projects
Sponsorship & Exhibiting
Policy/Advocacy Input
Volunteering
Other
How did you hear about LTCAM
*
Referral
Website
Social Media
Conference
Other
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Individual Members
Please select
*
Post secondary education - Health, Social Services, Housing, Long-Term Care
Retiree - Healthcare, Housing, Social Services, Education related to Older Adults
What program/school are you enrolled in?
*
What sector did you work?(Health care, housing, social service etc.)
*
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Agreement
I agree to receive electronic communications from the Long Term and Continuing Care Association of Manitoba.
*
Yes
No
I consent to having my information shared publicly on the LTCAM website.
*
Yes
No
I consent to LTCAM sharing my information with other LTCAM members.
*
Yes
No
Signature
*
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