Affiliation / Membership � Centre for IPE

							                                Centre for IPE, University of Toronto - Membership

1) General Member
                                                                                            Benefits
    Completed some formal IPE learning (duration of at
     least 2 hours)                                                   Invitation to participate in working groups/committees
                   AND one the following:                             Entry of your name into an annual draw for continuing
    Facilitated at least two IPE curriculum learning activities       professional development opportunities
    Participated formally in a Centre for IPE working
     group/committee
    Participated formally in at least one IPE/IPC related
     research project



2) Research Member
                                                                                            Benefits
    Participated as a principal investigator/co-investigator
     in at least one IPE/IPC related research project                 IPE scholarly activity recognition in Centre reports
                                                                      Invitation to participate in working groups/committees
                                                                      Entry of your name into an annual draw for continuing
                                                                       professional development opportunities



3) Educator Member
                                                                                            Benefits
       Completed formal IPE learning (minimum 20 hrs)
                               e.g.,                                  IPE scholarly activity recognition in Centre reports
    IPE facilitation, IPE coaching, on-line IPE facilitation         Invitation to participate in working groups/committees
    ehpic™ (Educating Health Professionals in                        Entry of your name into an annual draw for continuing
    Interprofessional Care) course                                     professional development opportunities
    Collaborative Change Leadership (CCL) program                    20% discount on Centre for IPE courses and materials
                               AND                                    Invitation to events sponsored by the Centre
    Facilitated/taught at least 8 hours of IPE/IPC faculty
     development and/or professional development offerings
                               AND
    Participated in the creation and implementation of at
     least one officially recognized UT IPE curriculum
     learning activity



4) Associate Member
                                                                                            Benefits
 Taught at least 8 hours in accredited Centre for IPE
  courses (e.g. ehpic™ course, CCL program)                           IPE scholarly activity recognition in Centre reports
                           AND                                        Invitation to participate in working groups/committees
 Created and implemented at least two recognized UT                  Entry of your name into an annual draw for continuing
  IPE electives                                                        professional development opportunities
                           OR                                         20% discount on Centre for IPE courses and
 Led a Centre for IPE working group/committee                         materials
                           OR                                         Invitation to events sponsored by the Centre
 Participated as a principal investigator/co-investigator in         Certificate of recognition
  at least one IPE/IPC related research project                       Eligibility to join Centre for IPE speaker roster
                                      Application Form (Please print)

Name:

Profession:

Organization:

Title:

Address:




Telephone:

Email:

General and Research Membership - material to include in application
 Supporting Details (below)
 CV

Educator Membership - material to include in application
 Letter of support from Chair / Dean / Senior Administrator
 Supporting Details (below)
 CV

Associate Membership - material to include in application
 Letter of support from Chair / Dean / Senior Administrator
 Supporting Details (below)
 CV

Supporting Details: Please provide details below as to how you met the criteria (name of
courses, programs, workshops, learning activities, working groups, research projects),
including date(s), location(s), duration(s), etc.




Signature: _______________________________ Date: __________________

Please submit your completed application form to Clare.Schlesinger@uhn.on.ca