Membership Signup Form

Approximately 10 minutes to complete

Thank you for your interest in joining the Canadian Concussion Network-Réseau Canadien des Commotions (CCN-RCC). To join the network, please complete this form.

We will use the information you provide for the following purposes:

To understand and describe, on aggregate, the CCN-RCC’s membership
To assist in setting ongoing priorities for the CCN-RCC
To notify you of opportunities to participate in the work of the CCN-RCC
To send you member communications, such as network updates and Annual Meeting information
To create your CCN-RCC member profile to be included on the CCN-RCC website

If you have questions or have problems with the form, contact info@ccn-rcc.ca.

Profile Information

First Name

Last Name

Email Address

Twitter Handle

Province/Territory

Are you a trainee or student?

(e.g., undergraduate student, graduate student, post-doc, resident)

Yes

What stage of training are you in?

Undergraduate student
Medical student
Medical resident
Masters student
PhD student
Postdoctoral fellow

Institution/Organization Information

Primary institutional affiliation/Organization

Department and faculty

Position/Job title

Secondary institutional affiliation, if applicable

What sector do you work in? (select all that apply)

Provincial, Territorial or Regional health services
Government
Non-profit
Primary Care Network
Private practice
University/Post-secondary institution
Other

Other professional sector

What training opportunities would you like to see offered by the CCN-RCC? (select all that apply)

Trainee research presentations and poster sessions
Web-based seminars/panel discussions/journal clubs
CCN-RCC trainee and early investigator social events
Peer-to-peer reviewing opportunities
Mentorship and career development partnerships
Trainee exchange programs
Other

Other training opportunities

Are you an early career researcher? (within 5 years of your first independent appointment)

Yes

What level of involvement would you like to have with the CCN-RCC? (select all that apply)

I want to provide feedback/input through surveys and focus groups
I want to participate in research working groups and committees if I am able.
I want to participate in the development of clinical, educational or outreach materials.
None of the above

Comments

Comments or suggestions on the involvement you would like to have with the CCN-RCC?

What value do you expect to receive from CCN-RCC membership? (select all that apply)

I will be more aware of current concussion research and practice in Canada
I will be more aware of research funding opportunities
I will be able to contribute my perspective to the concussion field
I will have a forum to disseminate my work
It will contribute to my professional development
Other

Other expectations

Communications Opt-in

Do you consent to receive CCN-RCC member communications, such as network updates and Annual Meeting information?

Yes

Demographic Information

The CCN-RCC is collecting demographic information from members as a means to support our commitment to reach an equitable, diverse and inclusive membership. This information is voluntary, confidential, and will not be visible on your member profile.

For questions, concerns or more information about the collection, use or disclosure of your personal information, please contact info@ccn-rcc.ca

What is your age?

18-24
25-34
35-44
45-54
55-64
65-79
80 and older
Prefer not to answer

Which of the following best describes your gender (select all that apply)

Man
Woman
Genderqueer/Non-binary
Other
Prefer not to answer

Other gender identity

Do you identify as a person with a disability?

Yes

Prefer not to answer

Which of the official languages do you speak fluently?

English
French
Both English and French
Prefer not to answer

I consent to share my information for review with the CCN-RCC

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