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  5. Nova Scotia Provincial Wait List
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Questions marked with a * are required Exit Survey
 
 
Nova Scotia Provincial Wait List
 
 
 
Please enter your information to place your name on a wait list for the next session to be scheduled in your region.
 
 
Participant Information
First Name : 
Last Name : 
Phone : 
Email Address : 
 
 
Organization Information
Organization Name : 
Street : 
City/Town : 
  : 
Postal Code : 
Phone : 
  : 
 
 
 
* Select the Nova Scotia Health Authority Zone you work in from the drop down menu (select one):
 
 
 
What is your position (job title) within the organization?
   
 
 
 
What is your professional designation?
 
RN
 
LPN
 
Social Worker
 
Occupational Therapist
 
Physiotherapist
 
Other
 
 
 
 
Choose the program that you are interested in attending:
 
24-hour P.I.E.C.E.S. Learning & Development Program
 
P.I.E.C.E.S. Leadership Performance Improvement Program
 
 
 
Are you aware of the performance objectives for this P.I.E.C.E.S. education program?
 
Yes
 
No
 
 
 
Thank you for your interest in the P.I.E.C.E.S. Program.