Membership Checkout Membership Information You have selected the Regular New membership level.The price for membership is $195.00 per year Do you have a discount code? Click here to enter your discount code Discount Code Account Information Username Password Show Password Confirm Password Note: Your password must be at least 8 characters long and contain upper and lowercase letters, a number, and a special character. First Name Last Name Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in hereMake a Gift Donation Amount $0.00$50.00$150.00$250.00 Other $ With almost 100,000 charities in Canada, choosing where to direct your support is a meaningful decision. When you give to CAMAP, you empower our members with the knowledge and tools they need to deliver compassionate care that respects patients’ autonomy and dignity. InformationPlease complete these additional fields for our records. ensure your information is correct and up to date. City Province/State AlbertaBritish Columbia'ManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonUSAOther Phone number Scope of MAID practice -- Please Select --ProviderAssessorAllied HealthCare CoordinatorAdministratorOther Specific involvement in MAID (if not included above) Please note: Provider refers to clinicians who have already administered or prescribed MAID. Assessors are those who have conducted eligibility assessments but have not administered/prescribed. Care Coordinator refers to those health professionals who help administer and coordinate organized MAID programs in an institutional or local setting. Please select all that apply (use CTRL or ⌘ for multiple) Medical background (if applicable) Not applicableFamily physicianNurse practitionerMedical specialistPalliative care specialistPalliative care NurseRNSocial WorkerOther health professional Medical specialty (if applicable) Licensing body If applicable (required for verification purposes) License number If applicable (required for verification purposes)Membership referenceFor new members only: In order to ensure a safe and respectful online community, CAMAP requires that new members provide a reference who can attest to their current or future involvement in MAiD-related activities. This includes, but is not limited to, a current or former member of CAMAP, an administrator or manager within your MAiD community, or a MAiD or medical program director/health authority administrator who grants MAiD-related privileges. Please enter your reference's email address here; they will receive an automated email requesting verification of your status. Please do not enter your own email address. Email Only valid email addresses will be accepted. Do not include the name of your reference plus their email.Membership Renewal AttestationPlease complete the following personal attestation to confirm your active involvement in assessing and/or administering MAiD in the last 12 months. You are asked to complete this to inform CAMAP whether you are an active assessor or provider, and provide a reference who can confirm your active participation in assessing or administering MAiD. Upon submission of this information, your reference will receive an automated email asking them to provide us with the required information. I attest that I have completed a MAiD assessment or have administered MAiD in the last 12 months. Yes - I have assessed for MAiD in the last 12 months Yes - I have administered MAiD in the last 12 months No - I have not assessed or administered MAiD in the last 12 months Reference Name Reference Email Reference Phone Billing Address First Name Last Name Address 1 Address 2 City Province Postal Code Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUS Armed ForcesUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone Payment Information Card Number Expiration Date CVC Discount Code I agree to the Membership agreement Processing...
