CONSENT
By completing this form and pressing Submit Registration, you have explicitly agreed to provide your contact information to the health authorities, Health Match BC, Health Link BC and the Ministry of Health, for the purpose of emergency health deployment.

Registrant Name *
Enter your full name; first name followed by last name.

Email *
Enter the email that you prefer be used to contact you. 

I am a registrant in good standing. *
Select Does not apply if you have not maintained your current registration status from your regulatory, oversight or credentialing body, for example because of retirement.
Select I am a registrant in good standing to indicate that you hold valid registration status from your regulatory, oversight or credentialing body.

Please indicate your registration number from your credentialing body.
While not mandatory, if you are able to provide this information, it is helpful to expedite the health authority’s hiring process.

Postal Code
Please enter your 6-digit postal code with no space in the middle. If you do not live in Canada, leave this field blank.

Which health authority do you currently reside in? *
In the event you are contacted by a health authority, the intent is to deploy you as close to your current residence as possible. Abbreviations in the form for health authorities are as follows:

• FHA – Fraser Health Authority
• IHA – Interior Health Authority
• NHA – Northern Health Authority
• VCHA – Vancouver Coastal Health Authority
• VIHA – Island Health (Vancouver Island Health Authority)
• Out of Province

Primary Telephone
While not mandatory, if you are able to provide this information, it may be helpful to expedite the health authority’s hiring process.

Secondary Telephone
While not mandatory, if you are able to provide this information, it may be helpful to expedite the health authority’s hiring process.

Registrant Specialty*
Select your primary professional occupation group (Allied Health Professional/ Dental Professional/ Emergency Responder/ Health Care Assistant/ Midwife/ Naturopath/ Non-Clinical Health Authority Employee/ Nurse/ Pharmacy/ Physician/ Podiatrist/ Student).

If applicable, enter your “Main Specialty” using the next drop-down.

Note: If you select Student as your “Registrant Specialty” you will have the opportunity to further define your field of study in the “Main Specialty” drop-down. If you are a Medical Resident however, please select Physician as your “Registrant Specialty” and Resident as your “Main Specialty”.

You can add subsequent “Registrant Specialties” by using the Add Another Item button. You may need to do this if you hold multiple specialties.

Other Specialty Information
Clinical registrants, please enter relevant sub-specialty information. If your sub-specialty is not itemized in the drop-downs noted above, you can add it in this box. Indicate most relevant training first and years of practice. (Example: Emergency 3 years)

All registrants, please select which best applies to you? *
Select the statement that best fits your current status at the time of signing up to the EHPR. Select Other if none of these apply to you and add whatever additional detail is required in the text box.

Select Not Applicable if you work in another field within the public sector (such as firefighters).

If you are a student, what health program are you enrolled in?
Indicate the program you are currently enrolled in and other pertinent information that would assist the health authority in the selection process.

Please indicate the year and last semester completed.
Enter the year and last semester you have completed in your program.

If you are currently employed by a health authority, please indicate which health authority? *
If you are employed by multiple health authorities, you may select multiple options. Please do NOT select Not currently employed by a Health Authority if you work for one of the health authorities listed, even part-time.

Please indicate your preferred health authority/authorities for deployment
Place an X by each health authority you would prefer for temporary assignment. Health authority links have been provided to assist in completing this section and to determine the proximity to your home location. Please note that where possible you will be contacted by the health authority of your residence.

www.islandhealth.ca  www.vch.ca  www.fnha.ca  www.providencehealthcare.org

www.fraserhealth.ca  www.interiorhealth.ca  www.northernhealth.ca  www.phsa.ca 

Preferred Location for Deployment
While not mandatory, this information will help health authorities in filtering the volunteers for those most easily deployed to a specific community in their region.

In the event of deployment, identify all of the placement options you would be prepared to support: *
Place an X by each of the following placement option(s) that you are prepared to support. You may choose more than one option. Health authorities will take this information into consideration when making deployment decisions. Individual conversations with regards to preferences and abilities will be held with health authorities before any assignment.

Have you received immunization training in the past five years? *
If you select yes, please also identify which training you have completed. If the training is different from those outlined in the dropdown field, please write it in the text box.

Preferred Duration of Deployment
Indicate when you can work during the temporary assignment. (For example: I am available every Tuesday, Wednesday and Friday or I can work Saturday and Sundays after 3 pm.)

Comments
If there is additional information you feel is important for a health authority to know, please enter it in the comments field.

I certify that I am the person named in this form. *
By checking this box, you are acknowledging all information provided is true and complete to the best of your knowledge.

Note: '*' sign indicates the field is mandatory