Thank you for being so interested in the ECHO Education Event. This form will take approximately 10 minutes to complete. This event will be held in person on the Hospital for Sick Children (SickKids) campus.

Completing this application form does not guarantee a spot in the event.
The application process is competitive, and detailed answers to the questions will benefit your application.

There is no cost to apply for or attend the ECHO Education Event.
The application deadline is February 11th, 2025 at 11:59 PM Eastern Time.

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* 1. I understand that completing this application does not guarantee me a spot in the ECHO Education Event. I understand that I will be notified of my application status by February 14th, 2025 latest.

I will contact project.echo@sickkids.ca if I need to know the status of my application sooner than February 14th, 2025.

SECTION A - APPLICANT INFORMATION

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* 2. Full Name

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* 3. Organization

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* 4. Primary Profession

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* 5. Specialty (If applicable)

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* 6. Primary Practice Setting

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* 7. How many years have you been a practicing health care provider (after completing training)?

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* 8. Approximately what percentage (%) of children in your practice have clinical needs related to pain?

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* 9. Phone Number

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* 10. Email Address

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* 11. Postal Code

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* 12. Are you a participant of Paediatric Project ECHO? Select all that apply.

SECTION B - PROFESSIONAL BACKGROUND AND INTEREST

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* 13. How old are the children you serve? (Select all that apply)

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* 14. What background or training do you already have in managing pain in children and youth?

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* 15. How will participating in this event support your professional development goals? What do you hope to achieve by participating?

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* 16. What paediatric pain topic(s) are you most interested in learning about?

SECTION C - ACCESSIBILITY
*Please note: to be eligible for financial support, applicants must have attended at least 3 Paediatric ECHO Sessions (Pain/Complex Care/Palliative Care/Obesity Management).

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* 17. Do you require financial support for travel-related expenses in order to attend this event?

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* 18. I intend to participate in all 14 hours (over two days) of the event.

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* 19. Considerations that may impact my ability to attend include: (select all that apply)

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* 20. I have my supervisor's approval to participate in this event.

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