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Become a Member
Membership Application
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Date:
*
Year
Year
2019
2020
2021
2022
2023
Month
Month
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Feb
Mar
Apr
May
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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?
*
- Select -
Organization (i.e. hospital)
University
Both
Please list the name of your primary organization:
*
What is your role at your primary organization?
*
Choose all that apply.
Clinician-Researcher
Researcher
Administrator
Fellow
Student
Other
If Other, please specify:
Please list the name of your primary university:
*
What is your role at your primary university?
*
Choose all that apply.
Assistant Professor
Associate Professor
Professor
Post-doctoral researcher/fellow
Student
Administrator
Other
If Other, please specify:
Area of Focus
Please provide 3 keywords that describe your area of focus:
Keyword 1
*
Keyword 2
*
Keyword 3
*
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.
Upcoming events
Funding opportunities
Networking & collaboration
Research & publications
None
Other
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.
I Consent
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