CRSN Education Request


If you wish to request education such as a course or a webinar that is not already in the CRSN Education Plan, please fill out the following form with as much detail as you have available.

Requests should be based on current stroke best practice recommendations, and will benefit the region in a measurable way.

Submissions will be considered by the Education Coordinator, and the CRSN Education Committee if time allows.

Submission does not guarantee that the request will be funded.

                            
Educational Event Details
Please fill in details of event you are suggesting.
Please include information on target audience such as discipline and experience level, and format (ie lunch and learn).

Please note that all fields are mandatory (use 'unknown' if necessary)
Title or name of event*

Please supply some form of name or title to refer to your proposal with.

List the title for the event you would like to provide.

Description of Event*

Please enter a description of the event or program

Please enter short description of the event. Include date of the event, location or delivery method, and anything else of a logistical nature that may be relevant to the event.

Reasons for Consideration*

Please enter a description of the event or program

Explain the value of the event to region and reasons why this request should be supported.

# of Attendees expected

Please enter a description of the event or program

Please estimate the number of people expected to benefit from the event, with a justification of the number.

Estimated cost if any*

Please enter a description of the event or program

Supply an estimated total cost in Canadian currency for the proposed event.

Upload files

If you wish, you may upload other documents (up to a maximum of 2 mb) in Word, Excel, PDF, image file, or similar format to support your proposal


                            
Identification information.
To complete this application, please include all information that is relevant to your request.
Name*

Please fill in your usual or full name

For contact & record keeping purposes

Email Address*

Please supply your email address

Enter email of person making program suggestion

Other Contact information

Please fill in your phone number or email address

Phone number or other contact info to allow us to contact you should we have further questions.

Area of Work within the CRSN*

Please make one choice

Choose the option that most closely identifies your relationship to the CRSN


                            
Submission of Request
Thank you for your request to fund an educational event.

By clicking on the submit button below, your request will be sent to the CRSN Education Coordinator.
Click to submit request

Contact us

Champlain Regional Stroke Network The Ottawa Hospital - Civic Campus Civic Parkdale Clinic, Main North 1053 Carling Avenue Ottawa, ON K1Y 4E9

Phone: 613-798-5555 x 16153
SPC Phone: 613-798-5555 x 16156