ACCESS TO SE HEALTH - @YOURSIDE COLLEAGUE®

Confidentiality Agreement

Instructions:

Complete the form by filling in the required information.
Carefully read and accept the statements of understanding.
Click on the SUBMIT button to send the form.
If you need assistance or have questions, please contact the SE Health FNIM Program at 1-800-463-1763 Ext. 142971. You can also email atyoursidefni@sehc.com.

This form is to be completed by the person who is requesting access to SE Health technology application, @YourSide Colleague®. Items marked with a red asterisk (*) are required.

First Name*:

Last Name*:

Email*:

Language Preference*:

I would like a tour of the @YourSide Colleague Website by one of the @YSC Team members.

Daytime Phone*:

Mobile:

Fax:

Job Title*:

Community / Organization*:

Mailing Address*:
(for sending certificates)

Postal Code*:
(for sending certificates)

Province / Territory*:

How did you hear about us?*

I consent to my email address being added to the SE Health First Nations, Inuit and Métis Program email list for information on upcoming education sessions and important program news.

I understand and agree to the terms of this confidentiality agreement. Click here to read the terms

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ACCESS TO SE HEALTH - @YOURSIDE COLLEAGUE®

Instructions: