JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Request an education session
Sign in to Google
to save your progress.
Learn more
* Required
Education sessions are available for the following physician groups:
*
Physicians in practice – learning at annual meetings, conferences, review courses, practice groups
Physician leaders – learning for current and aspiring academic, clinical and administrative leaders
CMPA Member
We require a CMPA member to sponsor requests for CMPA education sessions
CMPA Member Name:
*
Your answer
E-mail:
*
Your answer
Office telephone:
*
Your answer
Cell or home telephone:
*
Your answer
Logistics: Event coordinator or organizer
(if not the CMPA member)
Event coordinator or organizer name:
Your answer
Telephone:
Your answer
E-mail:
Your answer
Fax:
Your answer
Session details
Language of session:
*
English
French
Will this session be videoconferenced?
*
Yes
No
Location of education session:
Venue:
Your answer
Address:
Your answer
City:
*
Your answer
Province:
*
Choose
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Number of participants?
*
Intended for groups of 20 CMPA member attendees or more
Your answer
Preferred date and time
(Please include optional dates when possible)
Option 1:
Date:
*
MM
/
DD
/
YYYY
From:
*
Time
:
AM
PM
To:
*
Time
:
AM
PM
Option 2:
Date:
MM
/
DD
/
YYYY
From:
Time
:
AM
PM
To:
Time
:
AM
PM
Option 3:
Date:
MM
/
DD
/
YYYY
From:
Time
:
AM
PM
To:
Time
:
AM
PM
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
