Joining The Canadian Anaphylaxis Registry
YOUR CONTACT INFORMATION
Please fill out the information below to join the Anaphylaxis Canada Registry. When you submit this information for the first time, an e-mail will be sent to with your username and password.
Please note that all fields marked with asterisks * need to be completed before your application can be processed.
Personal Information
Salutation*
Dr
Mr.
Mrs.
Ms.
First Name*
Last Name*
Email*
Username
(To be assigned by Anaphylaxis Canada)
Password*
Confirm Password*
Language Preferred*
English
French
Would you like upcoming news to be sent to you by email?*
Yes
No
Would you like to be involved as a volunteer?*
Yes
No
If yes, what areas are of particular interest to you?
Participate in Research
Food Surveys
Event Planning
Administration
Fundraising
Campaign Support
Public Speaker
Writing/Editing
Translation
Other
What is your preferred mailing address?*
Home
Business
Please note that you are only required to complete the address section below for the preferred address that you selected.
Home Address Information
Country*
Select Country
Canada
United States of America
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guam
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Japan
Jordan
Kazakhstan
Kenya
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Ireland
Reunion (French)
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Tome and Principe
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Uganda
UK
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands (British)
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Address 1*
Address 2
City*
Province/State*
Select Province/State
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Kentucky
Maine
Maryland
Michigan
Minnesota
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
Ohio
Oregon
Pennsylvania
Queensland
Rhode Island
South Carolina
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
Postal/Zip Code (e.g. L4H 3J2 or 90210)
Phone (e.g. 5195554455)
Fax (e.g. 5195554455)
Business Address Information
Country*
Select Country
Canada
United States of America
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guam
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Japan
Jordan
Kazakhstan
Kenya
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Ireland
Reunion (French)
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Tome and Principe
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Uganda
UK
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands (British)
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Company Name*
Title
Department
Address 1*
Address 2
City*
Province/State*
Select Province/State
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Kentucky
Maine
Maryland
Michigan
Minnesota
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
Ohio
Oregon
Pennsylvania
Queensland
Rhode Island
South Carolina
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
Postal/Zip Code (e.g. L4H 3J2 or 90210)
Phone (e.g. 5195554455)
Ext
Fax (e.g. 5195554455)
Web URL (e.g. http://www.gosafe.ca)
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