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Joining The Canadian Anaphylaxis Registry
 
YOUR CONTACT INFORMATION



Please fill out the information below to join the Anaphylaxis Canada Registry. When you submit this information for the first time, an e-mail will be sent to with your username and password.

Please note that all fields marked with asterisks * need to be completed before your application can be processed.
 
Personal Information
Salutation*
First Name*
Last Name*
Email*
Username (To be assigned by Anaphylaxis Canada) 
Password*
Confirm Password*
Language Preferred*
Would you like upcoming news to be sent to you by email?*
Would you like to be involved as a volunteer?*
If yes, what areas are of particular interest to you?
What is your preferred mailing address?*

Please note that you are only required to complete the address section below for the preferred address that you selected.

Home Address Information
Country*
Address 1*
Address 2
City*
Province/State*
Postal/Zip Code (e.g. L4H 3J2 or 90210)
Phone (e.g. 5195554455)
Fax (e.g. 5195554455)

Business Address Information
Country*
Company Name*
Title
Department
Address 1*
Address 2
City*
Province/State*
Postal/Zip Code (e.g. L4H 3J2 or 90210)
Phone (e.g. 5195554455)  Ext 
Fax (e.g. 5195554455)
Web URL (e.g. http://www.gosafe.ca)


 

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