ONIG Membership Registration/Renewal/Update Form

This form is to be completed if you are a new member, renewing your current membership or updating your information.

*
Today's Date: (DD/MM/YYYY)

Today's Date: (DD/MM/YYYY)

First Name:

Last Name:

Reason for completing this form:

Reason for completing this form: Renewing Membership November 1,2009 to October 31, 2010

New Member Registration November 1,2009 to October 31, 2010

Updating Information - ONIG Member only

Updating Information - Member through RNAO

WORK INFORMATION

Title:

Area of Expertise:

Institution/Company/School

WORK/SCHOOL ADDRESS

Street:

City:

Postal Code:

Business Telephone:

HOME ADDRESS

Street:

City:

Postal Code:

Home Telephone:

Contact email for newsletters, updates or other ONIG communications:

Is this your work or home email address?

Is this your work or home email address? Home

Work

LHIN:

Map of LHIN structure

A Local Area Representative (LAR) is an ONIG member who volunteers to be a spokesperson for the ONIG members within a Local Health Integrated Network (LHIN) geographical area where he/she either lives or works.
Be part of the ONIG executive.
Be the source (main person) of communication for the individual LHIN group that they represent and will provide two-way communication between the group and ONIG.
Enhance communication among the LHIN group members and will be the voice for their concerns and collective ideas.
Communicate regularly through emails, teleconference calls, planned events or any means appropriate for the LHIN group. A planned event or teleconference call will be organized among the LHIN group members at least twice a year.
Report back to ONIG about the LHIN activities, at ONIG meetings, which will be published on the web site.

Would you be interested in becoming a LAR (Local Area Representative)?

Would you like an ONIG Executive to contact you and provide you with more information?

Comments:

Are you willing to have your name released for resource/consultation purposes or released at ONIG Education sessions for networking purposes?

Other (please specify)

SYSTEMS USED AT YOUR SITE/COMPANY

Order Entry:

Documentation:

Workload:

Other systems:

We are always looking for speakers or new topics for our Education Days. Suggestions/Comments:

If you are mailing a cheque or money order, print this survey from your browser file now, and mail the following to the address below.

Virginia Ellis
7392 8th Line Essa Utopia, Ontario L0M 1T0
PAYPAL IS NOT AVAILABLE AT THIS TIME!. November 24, 2009. If you wish to pay via PayPal, please click next. Your responses above will be saved and submitted to ONIG upon clicking 'next'.

ONIG Membership Registration/Renewal/Update Form

*Today's Date: (DD/MM/YYYY)

First Name:

Last Name:

Reason for completing this form:

Title:

Area of Expertise:

Institution/Company/School

Street:

City:

Postal Code:

Business Telephone:

Street:

City:

Postal Code:

Home Telephone:

Contact email for newsletters, updates or other ONIG communications:

Is this your work or home email address?

LHIN:

Map of LHIN structure

Would you be interested in becoming a LAR (Local Area Representative)?

Would you like an ONIG Executive to contact you and provide you with more information?

Are you willing to have your name released for resource/consultation purposes or released at ONIG Education sessions for networking purposes?

Order Entry:

Documentation:

Workload:

Other systems:

We are always looking for speakers or new topics for our Education Days. Suggestions/Comments:

*
Today's Date: (DD/MM/YYYY)