Application form | Pallium Central

I am applying to become a

LEAP Facilitator

I am applying to become a

Subject Matter Expert

Professional Credentials (e.g. CCFP, FRCPC, RN, CHPCN(C), BSW, MSW, BPharm):

Advanced training and/or certification in palliative care:

Position/Title:

Name of Institution(s):

Department (if applicable):

Not Selected
I work exclusively in palliative care
The majority of my work is palliative care but I also look after other patient populations
The majority of my work practice is not palliative care but I occasionally provide palliative care
Other

Less than two years
Two to five years
Six or more years
Not applicable

Please describe your work in palliative care in more detail:

Region

Province

Setting
Not Selected
Urban
Suburban
Rural (including small towns)
Remote
Other

Less than two years
Two to five years
Six or more years
Not applicable
If applicable, describe your experience:

If you have an academic appointment, please describe:

Briefly describe your experience as an educator/teacher:

Yes
No
Plan on attending a course soon