Begin Registration : Champlain Maternal Newborn Regional Program

Registrant info

Salutation
* First Name
* Last Name
* Email Address
* Company / Institution Name
* Phone Number
* City
* Role in your organization
* Specialty
* I work in the Ontario Health East Region (this region covers Prescott and Russell, Stormont, Dundas and Glengarry, Ottawa, Renfrew, Lanark, Leeds and Greenville, Frontenac, Lennox and Addington, Hastings, Prince Edward, Northumberland, and Peterborough)
	Yes No
* I agree that CMNRP can share my contact information with other members of the CoP
	Yes No
* Please describe your interest in applying to the Perinatal Mental Health Community of Practice (PMH CoP). (i.e. What might you be able to contribute to the PMH CoP? What benefits do you anticipate from participating in the PMH CoP?)