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PERSONAL AND PROFESSIONAL INFORMATION
Name: Organization:
Title: Email:
Telephone: Fax:
Address 1: Address 2:
City: Province/Territory: Postal Code:
Please select the area which best describes your work/area of interest:
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PRACTICE Direct clinical or public health services and/or management of such programs. Practitioners can represent community health centres, addiction treatment centres, non-profit organizations, government, or other organizations with demonstrated knowledge and skill.□
RESEARCH Research, as evidenced by peer-reviewed research grants and/or publications. This includes researchers who are affiliated with an academic institution, NGOs, government, or other organizations whose mission includes research.□
POLICY Writing or influencing policy decisions (both inside of government or those working for non-profit organizations, e.g., community-based organizations).□
OTHER For example, Family caregivers, people with Lived Experience, peer support etc.Please specify:
Please choose the thematic area to which your proposal is most closely aligned:
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First Nations, Inuit or Métis□
Child and Youth□
Family and Caregivers□
Service Systems□
Mental Health and the Law□
Seniors□
Science□
Workforce□
Stigma□
Housing and Homelessness□
Suicide Prevention□
Peer Support□
Substance Use□
Data□
Education□
Primary Care□
Other (please specify):2
BACKGROUND INFORMATION
1 What are you hoping to learn by attending the SPARK Training Institute? (150 words or less.)
2
How would you use the knowledge learned from the SPARK Training Institute in your day-to-day work? (150 words or less.)3
How do you learn best? (Eg. Small group discussions, reading, watching videos, lecture, actively working on a task, online learning. 150 words or less.)3
4
Why do you think you should be chosen for the 2013 SPARK Training Institute? (150 words or less.)PROPOSAL
1
Please describe the idea for which you would like to develop a knowledge translation plan. Make sure you include the topic, what you would like to do and who the target group is. (150 words or less.)2
Who are the key players (stakeholders) involved in your plan? Think about who will participate as well as those who need to be engaged to make it happen. (150 words or less.)4
