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Register for membership

Please fill out the form below to register for a CACPR Membership :
Please note that your account will need to be verified before you can access the system
Membership Type*:
Membership Length*:
Corresponding Language*:
*Title:
First Name*:
Last Name*:
Gender: Male Female
*Profession:
*Other Profession:
Hours/Week in Cardiac Rehab*:
Program * :
Organization :
  *Please enter a Program OR Organization
If your program or Organization is not represented, please choose *My program is not in this list from the program drop down and send an email with the full name, address and phone number of your program/organization. Admin will make the changes directly.
*Please indicate if the address applies to the Organization or Program.
Program    Organization    Both

Work Information

Home Information

Address 1*:
Address 2:
City*:
Postal/Zip Code*:
Ex: R3M 3V8 or 90210
Province/State*:
Other Province/State:
Note: If does not apply, put N/A
Country*:
Phone*:
Ex: 204-488-5854
E-mail Address*:
Referral By:
Referral Date: date picker
Yes No Include my name and work contact information in an online Membership Directory for members
Yes No I agree to receive CACPR’s monthly e-newsletters, meeting notices and updates about the organization;
Yes No Send me valuable information from JCRP?
Yes No Please keep me informed of CACPR’s educational products and services offered
 

Affiliations

AACVPR ACSM Atlantic Cardiac Rehab Network
Canadian Diabetes Association Canadian Physiotherapy Association Canadian/Provincial Kinesiology Association
Canadian/Provincial Nurses Association CCCN CCS
CRNO CSEP Heart & Stroke Foundation
Other:
 

Certifications

CCCN - CV Certified Exercise Physiologist (CSEP) Clinical Exercise Physiologist (ACSM)
Diabetes Educator (CDA) Exercise Specialist (ACSM) Program Director (ACSM)
Other:
 

Academic Background

Degree 1: Faculty: Year:
Degree 2: Faculty: Year:
Degree 3: Faculty: Year:
Degree 4: Faculty: Year:
Degree 5: Faculty: Year:
Degree 6: Faculty: Year:
 

Involvement in Cardiac Rehabilitation*

 

Credit Card Information

Credit Card*:
Credit Card Number*:
Expiration Date*: /
CCV Number*:
Subtotal: (CAD)
GST/HST: (CAD)
Total: (CAD)
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