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Registered Charity #72522 8126 RR0001
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History
Governance
Events
Donate
One Time Gifts
Monthly Donor
Memory
Leave a Legacy
Donate FAQ
For Clinicians
Education
Publications and Guidelines
Research
Mentors and MAiD Consultants
For the Public
Eligibility
MAiD Resources in Your Province or Territory
Public Resources
Countries Where Assisted Dying is Legal
FAQ
CMC
Topic Areas
CMC Project Summary
CMC FAQ
Contact
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Application Verification
Membership Reference Request Form
Applicant Name
Reference Information
Name
(Required)
First
Last
Email
(Required)
Are you a current or past CAMAP member?
(Required)
Yes - Current
Yes – Past
No
Relationship to Applicant
How do you know the applicant?
(Required)
How long have you known the applicant?
(Required)
Select one
< 1 year
1 – 3 years
3 – 5 years
5+ years
Applicant Involvement in MAiD
MAiD Involvement
(Required)
Is the applicant currently directly involved in MAiD?
Yes
No
Unsure
Please select all applicable roles: (Select all that apply)
(Required)
Provider
Assessor
Care Coordinator
Consultant providing expertise for MAiD requestors
Licensed MD/NP with anticipated work in MAiD
Administrator, allied health professional, or staff directly involved in MAiD delivery
Academic researcher with a focus on MAiD
Academic educator with a focus on MAiD
Pharmacist dispensing for MAiD
Individual in a professional relationship with a formal MAiD support organization
Individual with significant past professional roles related to MAiD
For the role(s) selected above, please indicate approximate years of experience:
(Required)
Please describe the applicant’s connection to MAiD:
(Required)
Recent Activity (Required for Provider/Assessor)
As you indicated the applicant’s role to be a
Provider and/or Assessor
, please complete the following:
Activity in past 12 months
(Required)
To the best of your knowledge, has the applicant independently completed a MAiD assessment or provided MAiD within the past 12 months?
Yes
No
Unsure
If Yes:
(Required)
MAiD assessment
MAiD provision
Both
Declaration
Declaration
(Required)
I confirm that the information provided is accurate to the best of my knowledge.
