Level 2 Courses Registration

Personal Information

* First Name: * Last Name: Phone # (Mobile): Phone # (Business): * Email:

Clinic Name: * City: * Province/State: * Postal/ZIP: * Country:

* Designation:

MD
PT
DC
OT
AT
NP
Other

Other (Please Specify):

* How did you hear about us?:

Online search
Social media
Colleague
Professional Association
Conference/seminar
Other

Other (Please Specify):

* Have you previously taken Shift's Level 1 Course?

Yes
No

* Have you completed any additional Concussion education/training outside of Shift's program?

Yes
No

Please Specify:

* Are you currently a Shift Concussion Management Member?

Yes
No

* Name as you would like it to appear on your Course Certificate (e.g. John Smith, DC) :

PRACTICE INFORMATION

Help us learn more about your practice style, setting and healthcare team.

How many Concussion cases do you typically see in a month?:

Which healthcare disciplines currently work within your facility (select all that apply):

Physiotherapist
Chiropractor
Massage Therapist
Athletic Therapist
Occupational Therapist

Osteopath
Physician (MD)
Naturopath
Other (please specify)

Specify:

As part of your multidisciplinary environment, which healthcare disciplines have you utilized or recommend to your concussion patients when needed (either within your own facility or outside in your community?) (select all that apply):

Physiotherapist
Osteopath
RMT
Chiropractor
Optometrist
Athletic Therapist
Occupational Therapist

Naturopath
Psychologist
Neuropsychologist
Audiologist
Speech and Language Pathologist
Medical Specialties (eg. Neurologist, Ophthalmologist, Psychiatrist, Physiatrist)
Other (please specify)

Specify:

Comments :

Do you have a formal relationship when it comes to referrals, collaboration, inter or intra-office communication with any of the following professions (either within your own facility or outside in your community) as it pertains to concussion patients? (Ie. is there open and direct communication back and forth regarding a shared patient's rehabilitation plan)

Physiotherapist
Osteopath
RMT
Chiropractor
Optometrist
Athletic Therapist
Occupational Therapist

Naturopath
Psychologist
Neuropsychologist
Audiologist
Speech and Language Pathologist
Medical Specialties (eg. Neurologist, Ophthalmologist, Psychiatrist, Physiatrist)
Other (please specify)

Specify:

Comments :

What is the duration of your initial concussion assessment appointment (in terms of direct contact with the patient)?:

Do you have access to a gym space/rehab space in order to complete exercises/exertion testing and training for your patients (as discussed at Shift's introductory course)?:

What is the duration of your follow-up post-injury patient visits (on average)?:

COURSE REGISTRATION

Which course(s) would you like to register for? (check all that apply)

* Shift Concussion Management Training: Level 2

Level 2: Applied Clinical Skills (Live):
March 31 - April 2, 2023 - Guelph
General("first-time admission"):
$722.50 + HST

General (Early Bird)("effective until Feb 17, 2023"):
$680.00 + HST

Returning, Non-Member("I've taken this course before but am returning to refresh my knowledge"):
$680.00 + HST

Returning, Member("I'm a current Shift Concussion Member and am returning to refresh my knowledge"):
$425.00 + HST

Level 2: Applied Clinical Skills (Live):
May 5 - 7, 2023 - Calgary
General("first-time admission"):
$722.50 + HST

General (Early Bird)("effective until Feb 17, 2023"):
$680.00 + HST

Returning, Non-Member("I've taken this course before but am returning to refresh my knowledge"):
$680.00 + HST

Returning, Member("I'm a current Shift Concussion Member and am returning to refresh my knowledge"):
$425.00 + HST

Level 2: Applied Clinical Skills (Live):
June 9 - 11, 2023 - Guelph
General("first-time admission"):
$722.50 + HST

General (Early Bird)("effective until Feb 17, 2023"):
$680.00 + HST

Returning, Non-Member("I've taken this course before but am returning to refresh my knowledge"):
$680.00 + HST

Returning, Member("I'm a current Shift Concussion Member and am returning to refresh my knowledge"):
$425.00 + HST

Level 2: Applied Clinical Skills (Live):
October 13 - 15, 2023 - Guelph
General("first-time admission"):
$722.50 + HST

General (Early Bird)("effective until Feb 17, 2023"):
$680.00 + HST

Returning, Non-Member("I've taken this course before but am returning to refresh my knowledge"):
$680.00 + HST

Returning, Member("I'm a current Shift Concussion Member and am returning to refresh my knowledge"):
$425.00 + HST

COVID CONSIDERATIONS: Shift Concussion Management will abide by all public health guidelines/restrictions that may be in place at the time of each individual seminar. Contact us before you register if you have any specific questions or concerns regarding COVID measures. In the rare event Shift must cancel a seminar due to COVID restrictions, you will be offered a full refund or registration transfer to the online course version or another live course date where available.

CANCELLATION POLICY: If you cancel 15 days or more before the course date, you will be given the option of a full refund (less a $80.00 cancellation fee), or a transfer of your registration to our online course version where applicable. You may also be able to transfer your registration to a different live course date. If you cancel with less than 15 days notice, you will not have the option of a refund, but a transfer to the online course version can be offered where applicable.

I have read, and acknowledge Shift's COVID and Cancellation policies.

MEMBERSHIP OPTION

For those who successfully complete all Level 2 training requirements, participants have the option of becoming a Member and Recognized Level 2 Trained Provider of the Shift Concussion Management Program. If you are already a Level 1 Member, your membership will be rolled into the Level 2 category with no added cost to you. Health Professionals interested in joining Shift's Level 2 Provider network are required to successfully pass all exams.

Membership Includes

Membership access to Shift's online resources, clinic forms, rehab videos, newsletters, and marketing materials
50% off repeat attendance to future Shift Concussion courses
Access to Shift Level 2 Provider logo
Listing on Shift's “Find a Provider” map (highlighted as Level 2 Provider)

Access to Shift's Clinic Support Team
An ImPACT account (Immediate Post Concussion and Cognitive Testing)
Access to Physiotec's Shift Concussion Module for home exercise prescription (physiotec.ca) - Optional
Opportunity for greater involvement with Shift Concussion Management (contact us for more details)

Fees Associated with Membership

Annual Membership Fees

$250

I am interested in becoming a Level 2 Member
Not right now

Note: you will not be charged a Level 2 membership fee until you have successfully completed all Level 2 courses and exams.