SickKids Clinical Leadership Observation Experience for Community Partners

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Section A: Online Application

Personal Information

Title

First Name *

Last Name *

Position/Professional Designation *

Area of Practice *

Registration Number *

Registration Issue By *

(Professional Licensing College or Organization)

Address *

Telephone Number *

Business Phone Number *

E-mail Address *

Emergency Contact Name *

Relationship to You *

Telephone Number *

Organization Information

Agency/Hospital/Institution Name *

Agency/Hospital/Institution Address *

Supervisor Name *

Supervisor Telephone Number *

Supervisor Email Address *

Learning Experience Information

Expected Start Date (dd/mm/yyyy) *

Duration of Observation *

What is your goal and learning objectives? *

What prior learning/experience have you had in relation to these objectives? *

Section B: Supporting

Current Resume/CV*

Please attach your most up to date resume/CV

Current Resume/CV *

Maximum file size: 516MB

Observation Agreement*

Please download the form from here*, complete and sign, and attach in the field below

Observation Agreement *

Maximum file size: 516MB

COVID-19 Attestation*

Please download the form from here*, complete and sign, and attach in the field below

COVID-19 Attestation *

Maximum file size: 516MB

Typically, a non-refundable application fee of $200 CAD will be applied. However, this fee is temporarily waived as a result of the current Ontario Health mandate for paediatric care across community partners.

Attestation *

It is understood that during your visit you may have access to confidential information. Checking this box indicates that you recognize that you are in a position of trust with The Hospital for Sick Children and agree to maintain confidentiality at all times

By checking this box, you attest that your organization supports and approves this Clinical Leadership Observation Experience application

I have read and reviewed the Terms and Conditions*

* Fields marked with an asterisk are required.

Healthier Children. A Better World.^TM