Membership restricted to physicians.

Personal Information (kept strictly confidential).

Required fields*

Gender:  M F *

First Name: *

Last Name: *

Home Address:* Street:

                              City / Town / Village:

                              Province / State:

                              Postal / Zip Code:

                              Phone:

OR Business Address:  Street:

                                        City / Town / Village:

                                        Province / State:

                                        Postal / Zip Code:

                                        Phone:

E-mail address: *

Physician?:  Yes   No *

If not a physician, what is your interest in our organization?

CMA member?:  Yes     No *

I agree to allow the CAPD to share the above personal information with only other CAPD members EXCEPT the nature of my disability:  Yes   No *

What follows are optional fields:

Specialty: Family Physician:

                  Other:

Medical School of Graduation:

Date of Birth:

Type of Disability:

Are you willing to be contacted by others with similar disability?  Yes   No

Are you willing to participate as a resource for disability in a teaching or educational capacity?  Yes   No

How did you hear about us?

Any other comments?