Organization Application Form

Based on the answers you provided, your organization falls into the Affiliate Member category and your annual membership fee is $150. If the fee is a barrier please contact Allyson Theodorou, Operations Manager at 1-866-681-6661 ext. 2.

Please check the following errors

Please enter name of peer program/organization
Please enter address of peer program/organization
Please enter city of peer program/organization
Please select province of peer program/organization
Please enter postal code of peer program/organization
Please select ontario health region
Please enter website of peer program/organization
Please enter email of peer program/organization
Please enter phone of peer program/organization
Please describe your program/organization
Please enter name of satellite office location
Please enter address of satellite office
Please enter city of peer satellite office
Please select province of satellite office
Please enter postal code of satellite office
Please enter email of peer satellite office
Please enter phone of peer satellite office
Select category you would place your organization
Please enter name of lead organization
Please enter main contact person name
Please enter main contact person email
Please enter main contact person phone
Please enter email subscriber name
Please enter email subscriber email
Please enter email subscriber title
Please enter email subscriber name
Please enter email subscriber email
Please enter email subscriber title
Please enter email subscriber name
Please enter email subscriber email
Please enter email subscriber title
Please accept terms & conditions
Please select payment method

Section A - General Information
(the information provided here will be posted on the OPDI website on the member section)

Name of Peer Program/Organization

Please enter name of peer program/organization

Address

Please enter address of peer program/organization

City

Please enter city of peer program/organization

Province

Please select province of peer program/organization

Postal Code

Please enter postal code of peer program/organization

Ontario Health Region

Please select ontario health region

Website

Please enter website of peer program/organization starting with https://

Please enter email of peer program/organization

Phone

Please enter phone of peer program/organization

Toll Free Number

Please describe your program/organization (including what activities and services you offer and opportunities for peers to be involved in the running of your program)

Please describe your program/organization

Do you have satellite offices? Yes No

Please select if you have satellite offices

Name of Location

Please enter name of satellite office location

Address

Please enter address of satellite office

City

Please enter city of satellite office

Province

Please select province of satellite office

Postal Code

Please enter postal code of satellite office

Please enter email of peer satellite office

Phone

Please enter phone of peer satellite office

Toll Free Number

Section B - Organizations Details

In what category would you place your organization?* Independent organization A flow through relationship with a larger organization Peer program within a larger organization

Select category you would place your organization

Section C - Main Contact Person's Information

Name

Please enter your name

Title

Please enter your email

Phone

Please enter your phone

List up to 3 other people who you would like to receive our emails, this may include other leaders in your organization and/or satellite offices:

Name

Please enter subscriber name

Title

Please enter subscriber title

Please enter subscriber email

Name

Please enter subscriber name

Title

Please enter subscriber title

Please enter subscriber email

Name

Please enter subscriber name

Title

Please enter subscriber title

Please enter subscriber email

Full Name I, apply for membership to the Ontario Peer Development Initiative and indicate my support for its mission, vision and values.

Please enter your full name

Section D - Payment Method

Select payment method* Credit Card Cheque E-Transfer

Please select payment method