Virtual CanREACH (PPP) Mini-Fellowship Training Program
Thank you for your interest in the CanREACH Patient centered mental health in Pediatric Primary care (PPP) Mini-Fellowship training program
NAME
*
First Name
Last Name
PRACTICE AREA (family physician, pediatrician, nurse, etc.)
*
Family Physician
Pediatrician
Nurse
other
* If other, please specify
ALBERTA HEALTH SERVICE ZONE
*
North Zone
Edmonton Zone
Central Zone
Calgary Zone
South Zone
Out-Of-Province
PRIMARY CARE NETWORK (PCN) AFFILIATE (if you are part of a PCN, which one?)
*
Not Affiliated
Aspen PCN
Big Country PCN
Bighorn PCN
Bonnyville PCN
Bow Valley PCN
Camrose PCN
Central PCN
CF-PCN
Chinook PCN
Cold Lake PCN
CWC-PCN
Daysland PCN
Drayton Valley PCN
Edmonton North PCN
Edmonton Southside PCN
Edmonton West PCN
Edmotnon PCN
Grand Prairie PCN
Highland PCN
Kalyna Country PCN
Lakeland PCN
Leduc Beaumont Devon PCN
Mcleod River PCN
Mosaic PCN
N/A
Oliver PCN
Palliser PCN
Peace River PCN
Peaks to Prairies PCN
Red Deer PCN
Rocky Mountain House PCN
Calgary Rural PCN
Saddle Hills PCN
SC-PCN
Sherwood Park PCN
St. Albert PCN
Vegreville PCN
WestView PCN
Wetaskiwin PCN
Wolf Creek PCN
Wood Buffalo PCN
ADDRESS (Mailing Address, The conference Material will be mailed out ahead of time)
*
PHONE NUMBER
*
-
Area Code
Phone Number
EMAIL
*
example@example.com
REGISTERING BODY (for certificates: Royal College, CFPC, etc.)
*
College of Family Physicians of Canada (CFPC)
Royal College of Physicians and Surgeons of Canada
N/A
Preferred Session Date & Location
September 2022 - December 2022 (Sept. 9th & 10th, 2022) WAITLIST ONLY
September 2022 - December 2022 (Sept. 9th & 10th, 2022) OUT OF PROVINCE WAITLIST ONLY
HOW DID YOU HEAR ABOUT THE PROGRAM?
*
CanREACH Website
PCN
Colleague
CanREACH Marketing(ie. PostCard/Email/Fax)
Other
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