2019 Nursing Leadership Assembly Application
RequiredRequired Question(s)
It's important to recognize that as a part of the application process, SEIU Healthcare will take into consideration factors such as your sector, region, past Leadership Academy experience  and union activism. Limited spaces are available at the 2019 Nursing Leadership Assembly.
 
Required 1.
First name:


 

50 characters left.
Required 2.

Last name: 


 

50 characters left.
Required 3.

Name of your workplace(s):


 

350 characters left.
Required 4.
Sector you work in:
Long-term Care
Hospitals
Home and Community Care
Other (please specify in comment)
  • Comment:

  • 500 characters left.
Required 5.
I am:
a chief steward
a steward
not a steward
Required 6.

Mailing address:


 

350 characters left.
Required 7.

 Personal email address (this will be how we communicate with you)


 

50 characters left.
Required 8.

Telephone number (home): 

 

50 characters left.
9.

Telephone number (mobile): 

 

50 characters left.
10.

What role(s) have you played within SEIU Healthcare (pick all that apply):


Leading workplace campaigns, events, and actions
Health and Safety Committees
Bargaining Committees
Volunteered at an SEIU event (swag booth, registration, other roles)
Told my story (Profiled by SEIU Heatlhcare Communications)
Recruited members for SEIU Heatlhcare events and campaigns
Participated in SEIU's Healthcare political action campaigns
Participated in Proffesional Practice education with SEIU healthcare
Volunteered for an RPN or a Nursing Convention with SEIU Healthcare
Attended an SEIU Healthcare Nursing Division nursing week event
Other  
Required 11.

Have you ever hosted an SEIU Healthcare Nursing Week in unit event(s)?

No
2016
2017
2018
Required 12.
Have you ever completed a workload review form?
Yes
No
Required 13.
Are you currently a member of a workplace professional practice committee? If yes, please describe.
 

50 characters left.
14.

Do you self-identify with any of the following:

LGBTQI2
Worker of colour
Indigenous or Aboriginal
Women
Worker with a disability
Millennial worker
15.

What SEIU Healthcare education programs have you participated in?

 

350 characters left.
16.

 Have you completed any of the SEIU Healthcare online education courses? If yes, which ones?:


 

350 characters left.
Required 17.

Are you a graduate of the Leadership Academy? If yes, please list all Academies you have attended.

 

350 characters left.
18.

Have you utilized Quality Assurance modules provided by SEIU Healthcare Nursing Division? (https://seiuhealthcare.ca/qa-learning-modules/)

Yes
No
Required 19.

Are you an active member of the RPNAO (Registered Practical Nursing Association of Ontario)? If yes, please describe your involvement in the comments. 

Yes
No
  • Comment:

  • 500 characters left.
Required 20.

Are you an active member of the RNAO (Registered Nurses Association of Ontario)? If yes, please describe your involvement in the comments. 

Yes
No
  • Comment:

  • 500 characters left.
Required 21.

Are you an active member of the NPAO (Nurse Practitioners Speaking for Nurse Practitioners)? If yes, please describe your involvement in the comments. 

Yes
No
  • Comment:

  • 500 characters left.
Required 22.

Are you an active member of any other professional association? If yes, please describe which organization and your involvement in the comments. 

Yes
No
  • Comment:

  • 500 characters left.
23.

Do you have any special requirements such as mobility issues, translation, dietary restrictions, or any other supports that may be required?

 

350 characters left.