Membership EHL Canada 2017 Membership If you are interested in becoming a member of Emerging Health Leaders please fill out the form below and indicate what node(s) you would like to join. If you have any trouble completing this form, cannot pay online or don't see a local node, please email us. Name* First Last Preferred Email* Enter Email Confirm Email This is the email that we will use to contact you.What city/town do you reside in?*This helps us understand where members are coming from and gives insight into where to launch new chapters/nodes.What node do you wish to join?*CalgaryEdmontonHamiltonMontrealNova ScotiaOttawaTorontoVancouverPlease choose the node you would like to be affiliated with.2017 Vancouver Membership Fee* Price: $ 25.00 CAD 2017 Toronto Membership Fee* Price: $ 25.00 CAD Total $ 0.00 CAD Are you a renewing member? Yes Credit CardIf your local node requires payment please provide your credit card information. If you do not have a credit card email firstname.lastname@example.org for alternative payment options. American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name What updates are you most interested in? Newsletter (industry news, EHL activities) Local area updates (events, announcements etc.) Promotions (e.g. job postings, continuing education or leadership programs) Other This is an informal poll to see what our members want to hear about. You will automatically be added to the Emerging health Leaders mailing list, but we send you and email to confirm you want to join.What best describes your work?* Clinical practice Administration or management Government or policy Research or education Private sector Non-health/healthcare related Other OrganizationPlease provide your primary organization affiliation (work, school, etc.)RolePlease describe your role with your organization or professionHow many years of work experience do you have?Please count only years when you were not enrolled in full-time education and include non-healthcare related years of work. If you are currently in school and have not started work, enter zero "0"How did you hear about Emerging Health Leaders? Website Mailing List LinkedIn Twitter Facebook Word of Mouth (friend, colleague, boss etc) Other CommentsThis field is for validation purposes and should be left unchanged.