Application Form

Name

Credentials

Institute

Address Line 1

Address Line 2

Office Phone Number

Cell Phone Number

Email

Assistant's Name

Assistant’s Phone Number

Assistant’s Email

Name of person who completed the application

Tell us about yourself / your practice:

Do you have a research coordinator?

Please enter their name, phone number and email

Do you use a local or central IRB/REB?

What type of practice are you a part of predominantly?

In what areas do you see yourself contributing to the Consortium? (check all that apply)

Patient recruitment
Protocol development
Protocol evaluation
Participation on the Scientific Committee
Participation on the Education Committee
Dissemination of results to our stakeholders (patients, local institutions, pharma
Other

Please provide more details about how you may contribute to the Consortium

By clicking this box you agree to receive information from The Canadian IBD Research Consortium. You also agree to remain an active member in good standing.

If, at any time you wish to no longer be a member, please notify us by email to The President, The Canadian IBD Consortium at circ.ccrm@gmail.com