Specialized Allied Health Care Student Registration Form

Student Details

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Mr

Mrs

Ms

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First name:

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Last name:

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Language Proficiency:

English

French

Bilingual

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Are you from NB?

Yes

No

If yes, what region are you from:
What community (city/town) are you from?

Education overview

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University or College:

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If other, please specify:

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Year of Enrollment:

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Expected year of graduation:

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Profession:

Contact Information

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Personal e-mail address 1:

Student e-mail address 2 :

Cell Phone Number:

Example: 506-555-1234

Employment section

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Are you considering working in NB when you complete your training?

Yes

No

Regions of interest:
Region 1 - Moncton
Region 2 - Saint John
Region 3 - Fredericton / Upper River Valley
Region 4 - Nord-Ouest/Northwest
Region 5 - Restigouche
Region 6 - Acadie-Bathurst
Region 7 - Miramichi
All of New Brunswick

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I understand that, by submitting my name and contact information, I agree to participate in the Provincial Registry of the New Brunswick Department of Health, a tool used for recruitment purposes. As such, I accept that, as a participant of this registry, the NB Department of Health may share my name and contact information with potential employers, namely the Regional Health Authorities and private clinics to assist them in their recruitment efforts. I understand that I can withdraw my consent at any time by e-mailing [email protected]