Membership Form

http://membership.chpca.net/

 Please use the above link for online registration for NLPCA & CHPCA

Palliative Care Association Joint Membership Form

 NLPCA     &    CHPCA

 

Please check the option desired:

                  New Membership                   Ο                             Individual ($50.00)                   Ο                        Renewal                      Ο                           


Membership Information: Please print

                                                                                                                                                                                         _______________________________________       
Title                                                                                     First Name                                                                                                Last Name

Mailing Address:

                                                                                                                                                             ________________  
Street Address

                                                                                                                                                                                            _______________________________________    
City                                                                                       Province                                                                                                 Postal Code

                                                                                                                                                                                       __ _______________________________________     
Health Region                                                                       Telephone                                                                                              Fax

                                                                                                                                                                                        _      _______________________________________
E-Mail Address

Role in Care:

Ο  Nurse                                                         Ο  Physician                                            Ο  Volunteer                                                         Ο  Pharmacist 
Ο  Social Worker / Counselor                         Ο  Clergy/pastoral/spiritual                      Ο  Occupational Therapist                                   Ο  Physiotherapist    
Ο  Other                                                   

CHPCA Newsletter (AVISO) sent by e-mail?          Yes        Ο                     No       Ο

CHPCA Interest Groups– The CHPCA has created 8 Interest Groups for members with similar interests.  If you would like to be a member of an Interest Group please indicate the group(s) below.  You must provide your e-mail address above to be invited to be connected to an electronic list serve for some of the Interest Group indicated.

     Ο Aboriginal Issues         Ο Social Workers/Counsellors               Ο Long Term Care/Continuing Care        Ο Rural and Remote Issues
     Ο Pediatric Issues           Ο Spiritual Advisors                               Ο Volunteers                                          

** Nurses Group Membership
– Registered Nurses who wish to be a member of the CHPCA Nurses Group are to pay a $20 membership fee directly to CHPCA. 


**Being a joint member also offers regular updates in provincial and national palliative care issues and
reduced rates to provincial and national conferences**

 Please make cheque payable to:

NEWFOUNDLAND AND LABRADOR PALLIATIVE CARE ASSOCIATION (NLPCA)

Mail to:

P.O. Box 39023

390 Topsail Road
St. John’s, NL  A1E 5Y7

 Membership each year is from May 1 – April 31.