Instructions:  Please complete the following form and click on the "Submit your booking" button at the bottom.
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First Name *

Last Name *

Profession - I am a * Select ... Chiropodist Dental Hygienist Dietician Health Educator/Promoter Kinesiologist Nurse Nurse Educator Nurse Practitioner Personal Support Worker Pharmacist Physician Physiotherapist Psychologist Recreation Therapist Rehabilitation Therapist Respiratory Therapist Speech Language Pathologist Social Worker Student Other (Please specify below)

Profession Other

Organization - I work for *

I work in Unit (or Department) *

Address *

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Phone *

Email *

Gender * Select ... Female Male Intersex Trans – Female to Male Trans – Male to Female Two-spirit Prefer not to answer Do not know Other

Other Gender

Age * Select ... under 20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Ethnicity Select Ethnicity Asian – East (e.g., Chinese, Japanese, Korean) Asian – South (e.g., Indian, Pakistani, Bangladeshi, Sri Lankan) Asian – South East (e.g., Malaysian, Filipino, Vietnamese) Black – African (e.g., Ghanaian, Kenyan, Somali) Black – Caribbean (e.g., Barbadian, Jamaican) Black – North American (e.g., Canadian, American) First Nations Indian – Caribbean (e.g., Guyanese with origins in India) Indigenous/Aboriginal Inuit Caucasian/White Latin American (e.g., Argentinean, Chilean, Salvadoran) Métis Middle Eastern (e.g., Egyptian, Iranian, Lebanese White – European (e.g., English, Italian, Portuguese, Russian) White – North American (e.g., Canadian, American) Mixed heritage (e.g., Black – African and White – North American) (Please specify BELOW) Do not know Prefer not to answer Other(s) (Please specify BELOW)

Other Mixed Heritage

Other Ethinicty

Highest Education Level Completed Select Education Primary (grades 1 - 8) Secondary (grades 9 - 12) College University Bachelor’s University Post-Graduate No formal education Do not know Prefer not to answer Other (please specify below)

Other Education

Which of these patient focused topics are relevant to you? (Please select all that apply) Asthma
Arthritis
Emphysema, COPD or other Lung Disease
Cancer
Diabetes
Heart Disease
High Blood Pressure
Osteoporosis
Other (Please specify below)

Other Relevant Topics

How did you hear about the workshop? *

Guidelines for participation in this health care provider workshop.

In order to benefit from this workshop, we ask you to:

• Come to the session as registered
• Take care of your needs (stand up, stretch, leave the room)
• Be respectful of others and their ideas
• Maintain confidentiality
• Turn off your cell phones/pagers
• Attend a practice session following two months of the workshop completion
• Participate in group discussion

I have read and agreed to the guidelines for participation. * Check here to confirm

Informed consent
I grant permission to Choose Health-Toronto Central, c/o South Riverdale Community Health Centre:

1. To contact me in the future for the purposes of providing self management related updates, such as additional programming, events, training, and research opportunities.
2. To share de-identified information collected in the workshop with external partners for the purpose of ongoing evaluation and quality improvement of the program.
3. To request responses via email, if applicable, to evaluation tools.

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