Health Care Organization Contact Registration

Reject Reason:

All fields marked with are required.

Login Information

Username:

User ID must have minimum 6 characters in combination of alpha and numeric.

Password: Re-type Password:

The password is case sensitive and must be: minimum 8 characters in length - NOT containing any spaces

Registrant

Date of submission

Name of Physician or Health Care Organization/Team/Practice

Title/Specialities

Address

Address Line 2

City

Province

Postal Code/Zip Code

Primary Contact Name

Primary Email Address

Re-type Email Address

Primary Phone:
- -

Organization Website

Organization Email

Organization Phone Number
- -

Describe your primary objectives or those of your health care team. This will be publicly displayed

Why are you or your health care team interested in joining Activate Aurora's Exercise is Medicine program?

How many physicians does your organization have?

How many physicians will be writing prescriptions to patients?

Do you have other healthcare professionals in your organization that will also be providing prescriptions to patients? (such as registered dietitians, pharmacists, physiotherapists, psychologist, nurse practitioner, etc.)

Yes

No

List the types and number of all prescribers here:

Patient Information

Do you or your Health Care Team see patients who are sedentary or inactive and are not reaching activity guidelines such as:

Adult or seniors below 150 minutes of moderate to vigorous physical activity per week?

Yes

No

Children or youth below 60 minutes of moderate to vigorous physical activity per day?

Yes

No

Note: Exercise is Medicine is primarily concerned with primary prevention and promotion of health lifestyles through physical activity. We do NOT exclude people who present with chronic conditions where properly prescribed activity would be beneficial to their health. All patients who can be physically active without direct medical supervision are encouraged to participate.

Physician or Health Care Team Consent

Prior to completing this application, the Physician Member Information Package was reviewed

Yes

No

You or your health care team will commit to semi-annual reporting requirements by tracking the number of prescriptions provided to patients?

Yes

No

Please provide the name and contact information of the person responsible for reporting.

Primary Reporting Contact Name

Primary Reporting Email Address

Secondary Reporting Contact Name

Secondary Reporting Email Address

NOTE*: Please email your logo to info@sportaurora.ca

Mission Statement: The Mission of Sport Aurora is to promote participation in sport and recreation for all citizens of the community we serve. Vision Statement: Sport Aurora is committed to be a progressive, dynamic leadership team promoting quality sport and recreation. Our Beliefs: Working together for the common good of sport. Providing sport opportunities for all. Demonstrating honesty, integrity and respect in our roles as community leaders in sport. Promoting the benefits of sport participation for all. Ensuring a safe, healthy, friendly and fun environment for all in sport Respecting all participants equally from the playground to the podium Encouraging fair play and adhering to the spirit of the rules Providing strong leadership support for our local sport organizations Recognizing the importance of volunteers’ contribution to sport Celebrating participation successes and expertise Working in partnerships and sharing resources and expertise both internally and externally. Recruiting, developing, retaining and recognizing competent, ethical and certified coaches and officials. A Member of VICommunity www.vicommunity.com, Powered by QC Technologies Inc., www.qcti.net