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You must have JavaScript enabled to use this form. Register for the CAPCE Program You must answer all of the questions asked to complete the registration process. It should take about 5 minutes. You cannot save or re-enter the survey. Notification of acceptance or decline will be sent to all applicants within one week of the registration close date. The Fundamentals of Hospice Palliative Care and the Fundamentals Enhanced programs are both prerequisites for CAPCE. If you have not completed these courses, please contact your local Palliative Pain & Symptom Management Program. Contact information is found at www.palliativecareswo.ca. If you have further questions, please contact our Program Assistant Betty Tucker. Personal Information: What region do you work in? - None -Lambton-KentGrey-BruceHuron-PerthLondon-MiddlesexOxford-ElginWindsor-Essex Personal Details: Last First Home Address: Address Address 2 City/Town State/Province ZIP/Postal Code Country Cell phone or home number: Best email for contact: Organization Details: Primary Employer: Organization Phone Number: Manager/supervisor Name: Do you work for more than one organization? - None -YesNo If yes, where else do you work? Your Role at Work: What is your professional designation? RN RPN NP Which of the following describes your area of practice? Choose all that apply. Chronic Care Geriatrics ICU/Critical Care Internal Medicine Oncology Palliative Care Pediatrics Other: Enter other… Have you completed the Fundamentals of Palliative Care or are you in the process of doing so? Proof of completion will be required upon acceptance. Yes No In what year did you complete the Enhanced Fundamentals Program? ONLY respond to this question if you are applying to attend in the London Middlesex Region. Please select one of the following set of training dates: Tuesday, March 5, 2024 from 1 – 3 pm Thursday, March 7, 2024, from 2 – 4 pm How did you hear about the CAPCE Program? Palliative Pain & Symptom Management Consultation Program website (www.palliativecareswo.ca) Palliative Pain & Symptom Management Consultation Program Educator In an education program (i.e. Fundamentals or LEAP) From your Manager/Supervisor From a peer Other (please enter): Other (please enter): Opt in or out permission: The Southwestern Ontario Palliative Pain & Symptom Management Consultation Program (PPSMCP-SWO) requests the following permissions to contact you regarding research or education events. We take your privacy seriously and we commit and confirm that we will not share your details and information and would only make contact with you from this program related to the two situations above (education events or research potential). We do maintain our registration information for 10 years. PPSMCP-SWO may use this email to send information about research opportunities regarding the education programs. Yes No PPSMCP-SWO may use this email to send information about future PPSMCP-SWO program education and events. Yes No This personal information is being collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact Privacy and Freedom of Information, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON,519-646-6100 ext. 65591.
