{"id":4858,"date":"2023-07-05T11:12:02","date_gmt":"2023-07-05T15:12:02","guid":{"rendered":"https:\/\/www.amom.net\/become-a-member-of-amom\/"},"modified":"2025-01-14T12:17:31","modified_gmt":"2025-01-14T17:17:31","slug":"registration","status":"publish","type":"page","link":"https:\/\/www.amom.net\/en\/registration\/","title":{"rendered":"Membership Form and Account Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4858\" class=\"elementor elementor-4858 elementor-1759\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-ab0d37e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ab0d37e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-0c7be67\" data-id=\"0c7be67\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\n\n\n\n\t\t<div class=\"elementor-element elementor-element-0cf3655 elementor-widget elementor-widget-wysiwyg_oktane\" data-id=\"0cf3655\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wysiwyg_oktane.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wysiwyg\"\n        >\n            <div class=\"page-section page-section__wrapper\">\n                <div class=\"wysiwyg__wrapper\">\n                    <div class=\"wysiwyg__content wp-content\">\n                        <p>This form allows you to become a member of AMOM (certain conditions apply) or to create an online account.<\/p><p>Details on the type of registration:<\/p>                    <\/div>\n                <\/div>\n            <\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e06a513 elementor-widget elementor-widget-wysiwyg_oktane\" data-id=\"e06a513\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wysiwyg_oktane.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wysiwyg\"\n        >\n            <div class=\"page-section page-section__wrapper\">\n                <div class=\"wysiwyg__wrapper\">\n                    <div class=\"wysiwyg__content wp-content\">\n                        <h3>''Member'' Registration :<\/h3><ul><li>Select this type of registration if you are an existing member of the AMOM and want to create your online account.<\/li><li>Select this type of registration if you wish to become a member of the AMOM. You will automatically have an online account.<\/li><\/ul><p>A physician choosing to become a member of AMOM does so freely and voluntarily. They commit to adhering to the Statutes and Regulations of the Montreal Association of General Practitionersl. Additionally, the physician consents to being included in the distribution list for electronic communications intended for members (FLASH-AMOM). They retain the right to unsubscribe at any time after receiving a FLASH-AMOM. The Association will act on their behalf when the interests of general practitioners or the profession require.<\/p>                    <\/div>\n                <\/div>\n            <\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-340f830 elementor-widget elementor-widget-wysiwyg_oktane\" data-id=\"340f830\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wysiwyg_oktane.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wysiwyg\"\n        >\n            <div class=\"page-section page-section__wrapper\">\n                <div class=\"wysiwyg__wrapper\">\n                    <div class=\"wysiwyg__content wp-content\">\n                        <h3>''Other Health Professional'' Registration :<\/h3><ul><li>Select this type of registration if you are another health professional (resident, specialist physician, nurse, pharmacist, physiotherapist, etc.) and want to create an online account to register for medical training. (Modifications may be made without notice).<\/li><\/ul>                    <\/div>\n                <\/div>\n            <\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6f5962a elementor-widget elementor-widget-wysiwyg_oktane\" data-id=\"6f5962a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wysiwyg_oktane.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wysiwyg\"\n        >\n            <div class=\"page-section page-section__wrapper\">\n                <div class=\"wysiwyg__wrapper\">\n                    <div class=\"wysiwyg__content wp-content\">\n                        <h3>''Non-member Physician'' Registration :<\/h3><ul><li>Select this registration type if you are a non-member physician of the AMOM and wish to create an online account to enroll in Continuing Medical Education (CME) activities (fees will be charged for activities starting from June 1st).<\/li><\/ul>                    <\/div>\n                <\/div>\n            <\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c572280 elementor-widget elementor-widget-wysiwyg_oktane\" data-id=\"c572280\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wysiwyg_oktane.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wysiwyg\"\n        >\n            <div class=\"page-section page-section__wrapper\">\n                <div class=\"wysiwyg__wrapper\">\n                    <div class=\"wysiwyg__content wp-content\">\n                        <h3>''Non-Member Retired Physician'' Registration :<\/h3><ul><li>Select this registration type if you are a retired physician and not a member of the AMOM, and wish to create an online account to enroll in Continuing Medical Education (CME) activities (fees will be charged for activities starting from June 1st).<\/li><\/ul>                    <\/div>\n                <\/div>\n            <\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e182d1b eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"e182d1b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n\t\t        <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/en\/wp-json\/wp\/v2\/pages\/4858' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_24'>Membership type<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_5_24' class='large gfield_select'     aria-invalid=\"false\" ><option value='Member' >Member<\/option><option value='Other healthcare professional' >Other healthcare professional<\/option><option value='Non-member Physician' >Non-member Physician<\/option><option value='Non-Member Retired Physician' >Non-Member Retired Physician<\/option><\/select><\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_21'>Identifier (for connection)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >All personal information below will be for the exclusive use of the Association, and it will only be used in case of necessity.<\/div><div id=\"field_5_3\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_3'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'>Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>License number (CMQ)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_25'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_22\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'> Name of practice location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Practice address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_5_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_5_8_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_8_1' id='input_5_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_5_8_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_8_3' id='input_5_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_8.4' id='input_5_8_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_5_8_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_8_5' id='input_5_8_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_5_8_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_23'><div class='gchoice gchoice_5_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='1' checked='checked' id='choice_5_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_1' id='label_5_23_1' class='gform-field-label gform-field-label--type-inline'>I agree to display my professional contact information on the members' directory (visible only to other members).<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_10\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'>Practice phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_5_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_9\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_5_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_5_9_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_9_1' id='input_5_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_5_9_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_9_3' id='input_5_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_9.4' id='input_5_9_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_5_9_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_9_5' id='input_5_9_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_5_9_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_11\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>Home phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_5_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'>Cellphone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_5_12' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_5_13' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_14' id='input_5_14' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_5_14_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_14_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_14' class='gform_hidden' value='https:\/\/www.amom.net\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >By subscribing, I agree to be added to the mailing list for electronic communications to members (FLASH-AMOM). I can, if I wish, unsubscribe at any time after sending a FLASH-AMOM.\r\n\r\nBy subscribing, I agree to be added to the mailing list for electronic communications to members (FLASH-AMOM). I can, if I wish, unsubscribe at any time after sending a FLASH-AMOM.\r\n\r\nThe Association will act on my behalf when the interests of general practitioners or those of the profession so require.\r\n<\/div><div id=\"field_5_17\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_17'>In witness whereof I have signed the<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_5_17' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' 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Details on the type of registration: &#8221;Member&#8221; Registration : Select this type of registration if you are an existing member of the AMOM and want to create your online account. 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