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NCIME Scholars Portal
IFLDP Intake Form
Name
*
Email Address
*
Phone
*
What is your preferred method of communication?
What is your preferred method of communication?
Email
Phone Call
City
*
State/Province
*
ZIP / Postal Code
*
Do you self-identify as Indigenous?
*An Indigenous person who is a recognized and accepted member of a First Nations, Inuit or Métis Nation in Canada with demonstrated connections and commitment to advancing Indigenous health or Indigenous medical education.
Yes
No
Please select all that may apply.
First Nations
Métis
Inuk
Please specify which Nation you are from.
Please enter your degree(s)/designation(s).
*
Please enter the name of your title(s) (Clinical educator, Faculty, Director, etc.)
*
What is/are your speciality/specialties?
*
Do you have any accessibility needs?
*
Yes
No
Please describe your accessibility needs.
Do you require any learning accommodations?
*
Yes
No
Please describe your learning accommodations.
Do you have any dietary restrictions?
*
Yes
No
Which dietary restrictions do you have?
Media Release Form
*
Please copy and paste the URL into a new tab, download the PDF, read the PDF and sign.
Please upload your signed Media Release Form here.
*
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Consent
*
Yes, I agree with the
NCIME Protection of Electronic Data Policy
and
NCIME Privacy Policy
.
Submit IFLDP Intake Form