IFLDP Intake Form

Name *

Email Address *

Phone *

What is your preferred method of communication?

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.YesNo

Please select all that may apply.First NationsMétisInuk

Please specify which Nation you are from.

Please enter your degree(s)/designation(s). *

Which medical school are you associated with? *

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? *YesNo

Please describe your accessibility needs.

Do you require any learning accommodations? *YesNo

Please describe your learning accommodations.

Do you have any dietary restrictions? *YesNo

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. *

No file chosen

Please upload your headshot and a short bio. *

Drag and Drop (or) Choose Files

Consent *

Yes, I agree with the NCIME Protection of Electronic Data Policy and NCIME Privacy Policy.