Member Application Form
Name
Email
Phone
Street Address
City
State/Province
Postal Code
Country
Qualifications
Institution
Year
Involvement in General / Family Practice
PART-TIME
FULL-TIME
Current position/Occupation/Parish of Practice
Interests (a) Medical
(b)Non-Medical
In what area can you serve as a member CCFPJC
What aspect of development of CCFPJC would you be willing to assist with
Administrative
Community service
Continuing Education Committee
Event/Workshop/Conference Planning
Executive
Membership Committee
Newsletter
Nomination/Election Committee
Social Media
Sponsorship Committee
Website Management
Organizing of CME Activities
Primary Care Research
Advocacy
Membership & Mentorship
Fund Raising/Finance
Other
Date
Time
Membership Fees ACTIVE CHAPTER Members FULL Registration Fee: $6,500.00 FULL Renewal Fee: $6,500.00 Discounts may apply based on membership category; please see below ACTIVE DIRECT Members Registration fee: FULL Renewal fee: FULL RETIRED and HONORARY Members (must apply directly to CCFP secretariat) Registration fee: FREE Renewal fee: FREE ASSOCIATE MEMBERS (must apply directly to CCFP secretariat) (Interns and Residents in FM program) 4 year limit Registration fee: FULL Renewal fee: 50% discount STUDENT MEMBERS (must apply directly to CCFP secretariat) (Medical Students) No automatic renewal; will need to demonstrate student status by mail or email Registration fee: Free Renewal fee: Free SUSTAINING MEMBERS (must apply directly to CCFP secretariat) Health Professionals allied to Medicine Registration fee: FULL Renewal fee: 50% discount Doctors (Specialists/Consultants) in disciplines other than Family medicine Registration fee: FULL Renewal fee: 25% discount CORPORATE MEMBERS Please contact us
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