Information Sheet for First Year Paediatric Residents

Residents Section

Information Sheet for First Year Paediatric Residents

Please complete and submit this information sheet if you are a physician who is a first-year resident enrolled in a postgraduate training program in paediatrics.

Contact Information

Last Name:
First Name:
Initial:
Salutation:

Business Address:
City:
Province/State:
Postal Code:
Telephone:
Fax:
E-Mail:

Home Address:
City:
Province/State:
Postal Code:
Telephone:
Fax:
E-Mail:

Preferred Language:
Preferred mailing address:
Date of Birth: (MM/DD/YYYY)
Gender:

Education
University of postgraduate studies:
Current year of paediatric residency:

Personal Information

The CPS realizes the great importance of protecting the personal information of its members. The society does not sell its mailing list, however, from time to time we are asked to share information (mailing addresses only) with other non-profit organizations for educational or statistical purposes. If you wish for your name to be excluded from these lists, please check below.

I wish for my information to be excluded from these requests

Declaration

I solemnly and sincerely declare that while a member of the Canadian Paediatric Society, I will observe the bylaws; I will support and further the interests of the Society and its objectives; I will at all times within my power to uphold the dignity and welfare of the Society and its members. I further agree to pay the prescribed fees.

Yes

Updated: September 2009