ACPAC Program

ACPAC 2020-2021 Program Application

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 / Workplace Details

Institution Name

Address

Street Address Address Line 2 City Province Postal Code

Business Phone

Business Phone Extension

Business Fax

Professional Information

Institution from which Professional Degree was issued

Professional Designations

Year of Graduation

0 of 4 max characters

Primary Administrative Contact

Institution / Workplace

Name

Prefix First Last

Admin Phone

Admin Extension

Admin Email

Admin Address

Street Address Address Line 2 City Province Postal Code

Prerequisites

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

Total Assessment of Inflammatory Polyarthritis Training Course offered by The Arthritis Society, Ontario Division

Date Total Assessment of Inflammatory Polyarthritis Training Course completed

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

Date Assessment and Management of Rheumatic Diseases completed

An equivalent course to the above

Equivalent course name and date completed

None of the above

CPSIA Course

I have registered for an upcoming CPSIA course

ACPAC 2020-2021 Program Application

Institution / Workplace Details

Professional Information

Primary Administrative Contact

Prerequisites

Locations