General Information:

For renewing members, click here

First Name:

Last Name:

Current Position:

Base Speciality:

Attending Staff Resident/Fellow

Hospital:

Address:

City/Town & Province/State:

Postal/Zip Code:

Business Telephone:

Email:

Do you wish to be added to the CCCS discussion email list?

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MEMBERSHIP FEES:

Full Member, Attending Staff, $ 200/Year

Affiliate Member, Residents and Fellows, $ 25/Year

To make a tax deductible donation to the CCCS, click here.

Membership Fee

$200.00 Full Member $25.00 Affiliate Member

PAYMENT OPTIONS:

Cheque:

• Payable to: The Canadian Critical Care Society

Internet Banking or Credit Card

• Securely pay membership fees directly from your PayPal account, linked bank account or credit card. You will be prompted for payment once you submit this form.