CRSN / RRAVCC - CRSN / RRAVCC

Hemispheres^®

Demande de licence utilisateur pour Hemispheres®

La soumission de votre formulaire dûment rempli génère une demande de licence qui vous permettra d’effectuer les divers modules Hemispheres. Notez que vous serez dirigé vers l'administrateur du site approprié, qui sera votre contact habituel.

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*

I am interested in completing the full Hemispheres program

I am only interested in the NIH Stroke Scale portion.

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.

Demande de licence utilisateur pour Hemispheres®

Please supply the registrant's Last Name

Please supply the registrant's First name

Please supply your email address

Please reenter your email address again

Please select the name of your organization

Please make one choice from the list provided

Please choose from one of the values listed

Please choose from one of the values listed

Please supply the name of your Manager or Scheduler

Please supply the name of your Manager or Scheduler

Please supply your manager's email address or phone number

What's New

Contact Us

Champlain Regional Stroke Network

Phone:

Stroke Prevention Clinic Phone:

Demande de licence utilisateur pour Hemispheres®

Please supply the registrant's Last Name

Please supply the registrant's First name

Please supply your email address

Please reenter your email address again

Please select the name of your organization

Please make one choice from the list provided

Please choose from one of the values listed

Please choose from one of the values listed

Please supply the name of your Manager or Scheduler

Please supply the name of your Manager or Scheduler

Please supply your manager's email address or phone number

What's New

Contact Us

Champlain Regional Stroke Network

Phone:

Stroke Prevention Clinic Phone:

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