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Username*

First Name*

Last Name*

Email Address*

Password*

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Primary Role*

Secondary Role (Select all that apply)

Pediatric Patient (0-18 years of age)Adult Patient (19 years of age or older)

Parent/GuardianFamily Member (other than parent)

ResearcherResearch Trainee

Healthcare ProviderClinician-Scientist

Health System Decision MakerResearch Staff

Other (please specify)

Year of Birth

What level of schooling are you currently enrolled in?

What is the highest level of education you have completed?*

What is the primary language spoken at home?*

What best describes your current gender identity?

City*

Province/State*

Country*

Institution/Organization:*

Are you currently or have you ever been involved in research?*

Are you currently or have you ever been involved in patient-oriented research?*

Are you affiliated with any of the following PORCCH partner organizations? Select all that apply.

BC SUPPORT UnitCanadian Child Health Clinician Scientist Program (CCHCSP)

CHILD-BRIGHTChildren's Hospital of Eastern Ontario (CHEO)

Holland Bloorview Kids Rehabilitation HospitalHospital for Sick Children (SickKids)

Ontario Child Health Support Unit (OCHSU)Ontario SPOR SUPPORT Unit (OSSU)

How did you hear about PORCCH? Select all that apply.

EmailInstitution

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