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EDUCATE IPV Champion Sign-Up (1 Minute)
Thank you for your interest in becoming a local IPV champion for the EDUCATE program. Please take a moment to complete the
brief
(
1 Minute
)
sign-up form below.
*
1.
First name:
(Required.)
*
2.
Last name:
(Required.)
*
3.
Email address:
(Required.)
*
4.
Profession:
(Required.)
Orthopaedic Surgeon
Orthopaedic Surgery Resident
Orthopaedic Surgery Fellow
Physician Assistant
Nurse (e.g. RPN, LPN, LVN, RN, MHRN, NP)
Cast Technician
X-Ray Technician
Physiotherapist
Clinical Researcher (e.g. assistant, coordinator, Investigator)
Booking Clerk / Administrative Position
Other (please specify profession):
*
5.
Name of hospital your fracture clinic is located in or affiliated with:
(Required.)
*
6.
Province your fracture clinic is located in:
(Required.)
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
*
7.
City your fracture clinic is located in:
(Required.)