Member Intake Form Member Intake Form Membership Eligibility In order to be eligible for membership with the Women’s Health Research Institute (WHRI), you must be a women’s or newborn health researcher, research trainee or research stakeholder based in British Columbia. If you are not based in British Columbia, you would be eligible for membership with the WHRI only if you have an established research collaboration with a WHRI member. In this case, the WHRI member with whom you collaborate would need to send an email confirming your collaboration to whri@cw.bc.ca. Please indicate the type of membership you are choosing:(Required)Full MemberAssociate MemberAffiliate MemberStudent/Trainee MemberPlease choose one of the optionsFull Member: For an individual involved in women’s health research for whom the WHRI would be the only research institute affiliation. Associate Member: For individuals who are involved in women’s health research, at least in part, but have a strong relationship with another research institute that they wish to maintain; the result is a dual membership with the WHRI and their current affiliation. Affiliate Member: For individuals who are extensively involved with another institute, but may have projects that would overlap with Women’s Health Research Institute. Student/Trainee Member: For undergrads, grad students, medical students, research and clinical fellows, international students, and any person in a degree-granting program who is engaged in research.Applicant infoName(Required) First Name Last Name Position / TitlePhone(Required)Email(Required) Degree(s)Please provide a short biography if desired. This biography will be published as part of your member profile on WHRI.org (Approx 250 words or less)Submit Photo for your online profile on WHRI.orgMax. file size: 30 MB. File must be 500x500 pixels, and less than 2MB. This image will published to your profile page on WHRI.org.I consent for WHRI to publish my photo to the WHRI.org website(Required) Yes No Academic AffiliationUniversityInstitutionAcademic RankAcademic FacultyAcademic DeptClinical Affiliation InformationClinical DeptType of ProviderClinical RoleHospital AgencyOtherSocial Media InformationLinkedinOtherWebsite URLCurrently a researcher on site at BC Women’s & Children’s?Currently a researcher on site at BC Women’s & Children’s? Yes No Research Institutions Affiliated withResearch Institutions Affiliated with BC Cancer Research Centre BC Children’s Hospital Research Institute BC Mental Health & Addictions Research Program Vancouver Coastal Health Research Institute Providence Health Care Research Institute BC Centre for Disease Control Research Institute BC Centre of Excellence in HIV/AIDS Other Research Themes Reproductive Infectious Diseases Women’s Cancers Maternal & Fetal Health Newborn Health Sexual and Reproductive Health Chronic Disease Global Health Genomics and Personalized Health Research Areas of InterestConsent to communicate?I consent for WHRI to publish my profile to the WHRI.org website(Required) Yes No Consent to communicate?(Required) I agree Consent to communicate enables WHRI.org to respond via email to your application request, and allows WHRI.org to add you to our monthly e-newsletter and any other relevant institute associated messaging. You may opt out of these messages at any time by unsubscribing.