Champlain Maternal Newborn Regional Program
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Applications for the Midwifery CoP
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Registrant info
Salutation
None
Dr.
Ms.
Mr.
*
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 Midwifery Community of Practice. (i.e. What might you be able to contribute to the CoP? What benefits do you anticipate from participating in the CoP?)
*
I would like my email address to be added to the CMNRP weekly news distribution list.
Yes
No
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