Application Trainee Verification

Trainee Reference Request Form

Applicant Name

Name(Required)

First Last

Email(Required)

Are you a current or past CAMAP member?(Required)

Yes - Current

Yes – Past

No

How do you know the applicant?(Required)

How long have you known the applicant?(Required)

What is the applicant’s current training status?(Required)

Medical resident

Nurse practitioner student

Other

Please provide the name of the institution or training program (if known):

Involvement in MAiD(Required)

Based on your knowledge, is the applicant currently involved in MAiD, or expected to be involved in MAiD practice in the future?

Yes

No

Unsure

Declaration(Required)

I confirm that the information provided is accurate to the best of my knowledge.

The Canadian leader for the community of professionals involved in medical assistance in dying (MAiD).

Email