Membership Application

Date: *

Year

Month

Day

Name: *

E-mail Address: *

This address will be added to the Leong Centre's email distribution list and you will receive updates on upcoming events, news, funding opportunities, etc. You may unsubscribe at any time by emailing leong.centre@sickkids.ca and requesting to be removed from our list.

Phone Number: *

SickKids staff can provide extension only.

What is your primary affiliation? *

Please list the name of your primary organization: *

What is your role at your primary organization? *

Choose all that apply.

If Other, please specify:

Please list the name of your primary university: *

What is your role at your primary university? *

Choose all that apply.

If Other, please specify:

How did you hear about the Edwin S.H. Leong Centre for Healthy Children? *

From a University of Toronto colleague

From a SickKids colleague

Attended a Leong Centre event/presentation

Read Leong Centre funded research

Leong Centre website

Other

If Other, please specify:

What type of information/resources are you interested in receiving from the Leong Centre? *

Choose all that apply.

If Other, please specify:

What benefits do you hope to gain from becoming a member? *

Choose all that apply.

Access to network of like-minded researchers

Access to collaboration opportunities

Access to funding opportunities

Knowledge about child and family health

Knowledge about health equity and social and structural determinants of health

Other

If Other, please specify:

I consent to having the information on this form shared with the Leong Centre's leadership team. *

I agree to promote the Leong Centre's vision and mission and attend at least one educational event per year.