Program Application – ACPAC Program

"*" indicates required fields

Name*

Prefix First Last

Email (Primary)*

Home Phone*

Home Fax

(if applicable)

Cell Phone

Address*

Street Address Address Line 2 City Province Postal Code

How did you hear about the ACPAC program?*

Institution Name

Address

Street Address Address Line 2 City Province Postal Code

Business Phone

Business Phone Extension

Business Fax

Institution from which Professional Degree was issued

Professional Designations*

Year of Graduation

0 of 4 max characters

Institution / Workplace

Name

Prefix First Last

Admin Phone

Admin Extension

Admin Email

Admin Address

Street Address Address Line 2 City Province Postal Code

Please indicate which of the following preparatory courses you have completed:

Clinical Practice Skills for Inflammatory Arthritis (CPSIA) program offered by the Arthritis Society

Date CPSIA program completed

Assessment and Management of Rheumatic Diseases: A skills workshop offered by the ACE Program

Date Assessment and Management of Rheumatic Diseases completed

Rheumatology Bootcamp 101: Assessment & Management of Rheumatic Disease

Date Rheumatology Bootcamp 101 completed

An equivalent course to the above

Equivalent course name and date completed

None of the above

Planned Course

I have registered for an upcoming program

Name and scheduled date

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.