WOHSS Membership Application

Transcription

1 Personal Information: Name: Month of Birth: WOHSS Membership Application Day of Birth: Identified Gender: Female Male Contact Information: Current Address: City: Province: Postal Code: Phone: Employment Information: Current Employer: Employer Address: City: Province: Postal Code: Position: Preferred mailing address: Home Work Years in present position: Demographic Information: Note: This information is being collected to understand the composition of our membership. This information may assist in future grant applications/sponsorship requests which will be focused on enhancing offerings that meet the needs of members. The provision of this information is optional. All information collected will be maintained in strict confidence and only used for the purpose for which it was intended. Ethnicity: Arab Asian/Pacific Islander Black Prefer Not to Disclose Caucasian First Nations/Metis Hispanic/Latino Age: >65 Marital/Family Status: Single/Divorced/Widow Single/Divorced/Widow with Children Married/Common-Law Married/Common Law with Children Salary: <$49,999 $120,000 to $149,999 $50,000 to $79,999 $150,000 to $174,999 $80,000 to $99,999 >$174,999 $100,000 to $119,999 Page 1 of 5

2 Current Professional Designations (select all that apply): Associate Safety Professional (ASP) Canadian Registered Safety Professional (CRSP) Canadian Risk Management (CRM) Certified Industrial Hygienist (CIH) Certified Occupational Health Nurse (COHN) Certified Professional Ergonomist (CPE) National Construction Safety Officer (NCSO) Health and Safety Administrator (HSA) Industry Experience (select all that apply): Agriculture/Forestry/Food Chemical/Allied Products Communications Computer/Electrical Construction Consulting Government/Public Sector Healthcare Insurance/Risk Management Services Manufacturing Canadian Registered Safety Technician (CRST) Certified Health and Safety Consultant (CHSC) Certified Health and Safety Management System Auditor (CHMSA) Certified Safety Professional (CSP) IOSH Chartered Fellow (CFIOSH) IOSH Chartered Member (CMIOSH) Chartered Professionals in Human Resources (CPRH) Mining Non-profit/Membership Organizations Oil/Gas/Petrochemical Services-Retail Services-Other Services-Travel/Recreation Transportation Utilities Wholesale Trade Which industry are you currently employed in (list one of the above)? Areas of Expertise/Interest (select all that apply): Incident Investigation/Reconstruction Audits Fire Prevention/Protection Ergonomics/Human Factors Law and Ethics Material Handling Generalist/Comprehensive Inspections Laboratory Safety Product Safety Education/Training Hazard Analysis Facilities and Equipment Design Speaker/Seminar Leader Risk Management Healthcare Emergency Planning Regulatory/Legislation Medical Service/First Aid/ CPR Public Safety Page 2 of 5

3 Industrial Hygiene/Biological Monitoring Transportation Management Systems and Programs International Workplace Wellness Occupational Health Others: What is your main area of expertise (list one of the above)? Education (include all): High School Certificate/Diploma Program Technical Institute College/University Name: College/University Name: College/University Program: OHS Experience: University Degree Masters PhD <1 year 1-3 years 3-5 years 5-10 years years >20 years Retired Reason for Joining (select all that apply): Networking Professional Development Mentoring Program Membership in other associations (select all that apply): Canadian Society of Safety Engineering (CSSE) American Society of Safety Engineers (ASSE) Auditing Association of Canada (AAC) America Industrial Hygiene Association (AIHA) Other(s): Alberta Occupational Health Nurses Association (AOHNA) Alberta Occupational Safety Auditor s Association (AOSAA) Alberta Society of Health and Safety Professionals Society (ASHSP) Page 3 of 5

4 Volunteer Interests (optional): Communications Committee Aims to create tools, provide oversight and help grow WOHSS through effective communications. Education Committee Aims to determine topics of potential interest to members and arrange speakers for meetings. Events Committee Aims to actively engage and attract members through a series of social events. Mentorship Committee Aims to organize activities through traditional, group, and reverse mentorship opportunities. Social Media Committee Aims to actively engage and attract members through social media channels. Sponsorship/Grants Committee Aims to help secure the long-term sustainability of WOHSS and increase incentives for members. Technical Question Resource Centre Committee Aims to help members address OHS technical questions through guided support. Website Committee Aims to provide a framework to get information out to potential and existing members. Signature I authorize verification of the accuracy of the information provided on this form. If accepted, I agree to be governed by the By-laws, Code of Ethics and Code of Conduct of WOHSS, as they are now or may hereafter become. I consent to WOHSS using my personal information provided in this application for purposes described in the WOHSS Privacy Policy. Signature of Applicant: Date: Page 4 of 5

5 Membership Classification: WOHSS Membership Payment General Member ($50) Applicable to women working in an OHS role in the province of Alberta. General members have the ability to apply for mentorship opportunities, vote in general elections, and run for a board position. Student Member ($25) Applicable to female students who are currently enrolled as a student on a full-time basis in an OHS program at a recognized school, college or university, or who have completed an OHS program at a recognized school, college or university within the previous calendar year. Student members have the ability to apply for mentorship opportunities, vote in general elections, but are not eligible to run for a board position. Associate Member ($50) Applicable to women working in an OHS role outside of Alberta, women who are interested in health and safety but not working in health and safety, individuals working outside of the OHS profession who provide associated services, and men. Associate members have access to WOHSS events, WOHSS technical questions, and other programs. Associate members are not eligible to apply for mentorship opportunities, vote in general elections or run for a board position. Member Payment Information: Please note: payment for annual membership dues must accompany this application. Membership Type: General ($50) Student ($25) Associate ($50) Cheque/Bank Draft VISA MasterCard AMEX CCV: Card Number: Card Holder Name: Expiration Date (MM/YY): All payments are required in Canadian Funds and must accompany your application. Payable to: Women in Occupational Health & Safety Society PO Box Madigan Plaza Calgary, AB T2A 3Y3 membership@wohss.com Page 5 of 5