Organizational Membership Application

We are excited that you will be joining Simulation Canada as an organizational member! The questions that follow will give us all the information we need to set you up, ensure your staff receive full website access, and allow us to direct communications to the right people.

The information you provide will be seen only by Simulation Canada staff and our Board of Directors, and used to process this application. We will not share this information with anyone.

1Welcome

2Basic Information

3Health Providers

4Key Contacts

5Voting Membership

6SIMadvocates

7Payment

8Certification

Before you begin this application, you might want to gather contact information for the following individuals at your organization:

Main administrative contact for issues relating to your membership (name, email, phone) – typically a Director or Dean
Financial contact for invoicing (name, email, phone)
Simulation lab/program coordinator or manager (name, email, phone)
Person who will act as your organization’s Voting Representative at our Annual General Meeting (name, email, phone)
Five staff/faculty members who will be granted full website access to our website on behalf of your organization (names and emails)

Legal name of your institution *

Department/division/faculty (if applicable)

Address *

Address Line 1

Address Line 2

City

Province

Code Postal

Organization Logo

Click or drag a file to this area to upload.

Please provide a logo so that we may post to our website.

Type of organization *

Please specify

Does your organization have a physical space greater than 1,000 square feet dedicated to simulation OR a mobile/in-situ simulation program? *

Does your organization integrate simulation into its educational curricula or safety/quality improvement activities? *

Does your organization have an active research and development agenda for simulation in healthcare? *

Which of the following healthcare and human service professions/providers do you educate or employ?

Acupuncture
Audiology
Chiropody or Podiatry
Chiropractic
Dental Hygiene
Dental Technology
Dentistry
Denturism
Developmental Services Work
Dietitics
Firefighting
Homeopathy
Kinesiology
Massage Therapy
Medical Laboratory Science
Medical Radiation Technology
Medicine
Midwifery
Naturopathy
Nursing
Occupational Therapy
Occupational Therapy Assistance
Opticianry
Optometry
Paramedicine
Personal Support Worker
Pharmacy
Physician Assistant
Physiotherapy
Physiotherapy Assistance
Podiatry
Police or Law Enforcement
Practical Nursing
Psychology
Psychotherapy or Mental Health Therapy
Recreation Therapy
Respiratory Therapy
Social Work
Speech-Language Pathology
Traditional Chinese Medicine
Veterinary Medicine
Others

Please specify

Please provide contact information for these key contacts.

The administrative contact should be a senior leader who we can contact about issues related to membership.
The financial contact is the person to whom the invoice should be sent.
The simulation manager should be the person most responsible for the day-to-day operations of your sim lab/program.

Name

Title/Role

Phone

Name

Title/Role

Phone

Name

Title/Role

Phone

Organizational Members who meet our membership rules are eligible to become Voting Members. Voting Members appoint a Representative to vote on their behalf at our Annual General meeting.

Do you wish to be considered for a Voting Membership?

Please complete the following questions to apply to also become a Voting Member. We will forward your application to our Membership Committee for review and approval, and communicate the outcome to you within 1 month.

Are you incorporated in and have a fixed place of business within Canada? *

Is your organization governed in accordance with a written constitution, general operating by-law or similar document? *

If you are accepted as a Voting Member, who will act as your organization’s Voting Representative at our Annual General Meeting?

Voting Rep Name *

First

Last

Voting Rep Title *

Voting Rep Email *

As an organizational member you can appoint 5 of your staff/faculty to be “SIMadvocates,” meaning they will have full access to all resources and functionality on our website. They will also be eligible to receive our special e-newsletters for SIMadvocates.

Additional SIMadvocates may be appointed for a modest annual fee. Please contact [email protected] for further information.

SIMadvocates have access to two special e-newsletters from Simulation Canada, should they wish to opt in. They are:

SIMadvocate newsletter – an exclusive newsletter for SIMadvocates from Simulation Canada with special community announcements, grant opportunities, news, highlights of recent research literature, and more to support their work in simulation.
Vendor announcements – new product information and significant promotion/sale announcements, sent from Simulation Canada on behalf of vendors who are Industry Collaborators with Simulation Canada. The Simulation Canada team will vet these to ensure content is appropriate and relevant.

Note: Consent to receive messages can be withdrawn at any time. For more information, please contact: Simulation Canada, PO Box 50214, 660 Eglinton Ave E, Toronto, ON M4G 2K0, Email: [email protected], Telephone: 866-639-1961

First Name

Last Name

Subscribe to newsletters:

SIMadvocate
Vendor announcements

First Name

Last Name

Subscribe to newsletters:

SIMadvocate
Vendor announcements

First Name

Last Name

Subscribe to newsletters:

SIMadvocate
Vendor announcements

First Name

Last Name

Subscribe to newsletters:

SIMadvocate
Vendor announcements

First Name

Last Name

Subscribe to newsletters:

SIMadvocate
Vendor announcements

Please note for credit card payments, we are unable to process them over the phone, only via online payment as indicated below.

Payment method option: *

Cheque
Credit Card†
Wire Transfer

For cheques an invoice will be issued upon confirmation with address details. For credit cards an invoice will be issued with pre-authorized credit card form to complete. For wire transfer an invoice will be issued upon confirmation with transfer details. †processing and service fees will apply

Annual Payment Cycle *

April 1 to March 31
October 1 to September 30

Please provide your preferred payment cycle for annual renewal.

By entering my name below I certify that the information given on this application is correct and complete.

Certified by

Name

Title/role

After you submit this application we will respond to you by email within 2 business days to confirm receipt. We will then generate an invoice and send it to the financial contact you provided. If you would prefer to pay by credit card, let us know and we will provide a pre-authorized credit card form to complete.

If you have any questions or would prefer to pay by a different method, please contact Tim Willett via [email protected].

Thank you again for your support!

Organizational Membership Application

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