Champlain Maternal Newborn Regional Program

Applications for the Midwifery CoP
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Information sur le participant

Salutation
* Prénom
* Nom de famille
* Courriel
* Nom de la compagnie \ institution
Numéro de téléphone
* Ville
* Role in your organization
* Specialty
* I work in the Ontario Health East Region (this region covers Prescott and Russell, Stormont, Dundas and Glengarry, Ottawa, Renfrew, Lanark, Leeds and Greenville, Frontenac, Lennox and Addington, Hastings, Prince Edward, Northumberland, and Peterborough)
Oui
Non
* I agree that CMNRP can share my contact information with other members of the CoP
Oui
Non
* Please describe your interest in applying to the Midwifery Community of Practice. (i.e. What might you be able to contribute to the CoP? What benefits do you anticipate from participating in the CoP?)
* I would like my email address to be added to the CMNRP weekly news distribution list.
Oui
Non
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