Membership Application Form

Thank you for your interest in becoming a member of the Canadian Women’s Heart Health Alliance.

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* 1. Personal information

Name:

Organization (If Applicable):

City:

Province:

Mailing Address:

Email Address:

Phone Number:

Twitter Handle (If Applicable):

Admin Assistant (If Applicable):

Name:

Email:

Phone Number:

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* 2. Please select which category you would best fall in:

Woman with lived experience

Clinical trainee

Research trainee

Clinician

Researcher

Clinician scientist

Other (please specify)

Preferred Working Group

The Alliance is comprised of an Executive Steering Committee, four Working Groups, a Trainee Representative and a Secretariat. Please visit our website for more information regarding the Alliance's governance structure.

All members of the Alliance are represented within each of the four Working Groups as either a Healthcare Professional Co-Chair, a Patient Advocate Co-Chair or an active participant. Listed below are brief descriptions for each of the four Working Groups.

The Advocacy Working Group is responsible for determining the best methods and means to enhance awareness about women’s cardiovascular health in multiple communities and constituencies across Canada and to stimulate new interest in the field of women’s cardiovascular health.

The Knowledge Translation and Mobilization Working Group is responsible for translating existing and new knowledge about cardiovascular health and disease in women; and creating sex-specific guidelines, tools and programs focused on improving outcomes for Canadian women.

The Health Systems and Policy Working Group is responsible for exploring cost-effective strategies to improve and monitor women’s cardiovascular health, and to promote these strategies based on findings.

The Training and Education Working Group is responsible for determining the best methods and means to enhance education and training about specific cardiovascular issues affection women. Projects will target various audiences such as the general public, physicians, nurses, students and allied health staff in a phased approach.

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* 3. Please select which working group you would like to join:
(First Choice)

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* 4. Please select which working group you would like to join:
(Second Choice)

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* 5. Based on your selection, describe how your unique perspective could add value to this working group?

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* 6. As a member, what are you hoping to get out of this Alliance?

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* 7. Do you currently reside in Canada?

Yes

If No, are you a Canadian citizen living / working abroad?

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* 8. What is your primary reason for choosing to volunteer for the Canadian Women’s Heart Health Alliance?

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* 9. Do you agree to the following statement: I am willing to advance cardiovascular care for women in Canada and can contribute my expertise from a patient, clinical, epidemiological, academic and/or research perspective.

Yes

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* 10. UPLOAD: Biography
Please provide a short biography (max one page). If you are a patient advocate, please share your heart story, information about yourself and/or any skills/areas of expertise you may bring to the Alliance.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. UPLOAD: Current resume/CV.
Please note: Not required but preferred. File limit is 16MB.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 12. How did you hear about the Canadian Women's Heart Health Alliance?

Promotional email from the Canadian Women's Heart Health Centre

E-newsletter from my association/network

Canadian Women's Heart Health Summit

Google search

It was promoted at a conference

Social Media

Word of mouth from a colleague/friend

Other (please specify)

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* 13. Are there any organizations or colleagues that you would recommend we connect with who may be interested in becoming a member of the Canadian Women's Heart Health Alliance?

Thank you for interest in becoming a member of the Canadian Women’s Heart Health Alliance. Please allow for 5-10 business days for the Secretariat to review your application. If you have any questions, please contact Lisa Comber at lcomber@ottawaheart.ca.

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* 1. Personal information

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* 2. Please select which category you would best fall in:

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* 3. Please select which working group you would like to join:(First Choice)

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* 4. Please select which working group you would like to join:(Second Choice)

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* 5. Based on your selection, describe how your unique perspective could add value to this working group?

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* 6. As a member, what are you hoping to get out of this Alliance?

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* 7. Do you currently reside in Canada?

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* 8. What is your primary reason for choosing to volunteer for the Canadian Women’s Heart Health Alliance?

Question Title

* 9. Do you agree to the following statement: I am willing to advance cardiovascular care for women in Canada and can contribute my expertise from a patient, clinical, epidemiological, academic and/or research perspective.

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* 10. UPLOAD: Biography Please provide a short biography (max one page). If you are a patient advocate, please share your heart story, information about yourself and/or any skills/areas of expertise you may bring to the Alliance.

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* 11. UPLOAD: Current resume/CV.Please note: Not required but preferred. File limit is 16MB.

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* 12. How did you hear about the Canadian Women's Heart Health Alliance?

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* 13. Are there any organizations or colleagues that you would recommend we connect with who may be interested in becoming a member of the Canadian Women's Heart Health Alliance?

* 3. Please select which working group you would like to join:
(First Choice)

* 4. Please select which working group you would like to join:
(Second Choice)

* 10. UPLOAD: Biography
Please provide a short biography (max one page). If you are a patient advocate, please share your heart story, information about yourself and/or any skills/areas of expertise you may bring to the Alliance.

* 11. UPLOAD: Current resume/CV.
Please note: Not required but preferred. File limit is 16MB.