Hemispheres®

Request for License
Completing this form sends a request for a license to allow you to work through the various modules of Hemispheres®.
Note that you will be referred to the appropriate Site Administrator, who will be your usual contact.


Please complete all information in full.

Fields marked * are mandatory

Registrant's Last Name*

Please supply the registrant's Last Name

Last name of registrant

Registrant's First Name*

Please supply the registrant's First name

1st (or given) name of person being registered

Registrant's Email*

Please supply your email address

Enter email of person being registered

Repeat Email*

Please reenter your email address again

Please enter the same email address again

2nd Email if desired

Enter another email address


Organization of Registrant*

Please select the name of your organization

Name of the organization, business, or hospital registrant works for. Please be sure to CLICK on your selection

Discipline or Position of Registrant*

Please make one choice from the list provided

Position within the Health Care System the registrant works for. Please be sure to CLICK on your selection

Place on
Continuum of Care*
Invalid Input

Where on the continuum of care best describess where the person being registered usually works? Please remember to CLICK on your selection.

Years in Practice*

Please choose from one of the values listed

Years working with Stroke Survivors*

Please choose from one of the values listed


First Name of Manager or Scheduler*

Please supply the name of your Manager or Scheduler

Please provide the first name of Manager, Shift Scheduler, or Edu Coordinator

Last Name of Manager or Scheduler*

Please supply the name of your Manager or Scheduler

Please provide the last name of Manager, Shift Scheduler, or Edu Coordinator

Manager Email*

Please supply your manager's email address or phone number

Email of Manager listed above


Please place check marks all areas that apply*

Please check at least one item

Submit Memorandum of Agreement

You can upload a signed Memorandum of Agreement if you wish


Submit Registration

Once form is fully filled out, click here to submit registration.


The CRSN invites health care professionals who work within the
Continuum of Stroke Care and are situated within the Champlain Region
to participate in educational events dedicated to best practices in Stroke Care.

All information gathered in this form is done so in confidentiality, and will not be used
for purposes other than for the explicit event for which data is being gathered.

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