Prevention Practitioner Training Registration Form

Thank you for your interest in Prevention Practitioner training.

Please fill out the entire form.

If you have questions, please contact us at

    Mailing address (where you want your training materials mailed prior to the session):

    How many years have you been in practice (current health care profession)

    Do you currently work in primary care?


    Where do you currently practice? (Please provide information in the space provided)

    With respect to your main practice setting, describe the population primarily served by you in your practice. (Select all that apply)

    Geographically isolated/remoteIndigenousRuralSmall townUnderservedUrban/suburban

    Why are you interested in Prevention Practitioner training? (Please choose one answer)

    Personal/professional developmentI’m interested in bringing the BETTER program to my organizationMy primary care organization is interested in having a Prevention PractitionerOther

    Is your main practice setting receiving implementation support from the BETTER Institute? Implementation support means that members of your practice are currently working with the BETTER Institute team to help integrate the program into your workflow. (Please choose one answer)

    YesNoI don't know

    Do you intend on practicing as a Prevention Practitioner? (Please choose one answer)

    YesNoNot sure

    Please select the choice with which you best identify (Please choose one answer)

    MaleFemaleSelf-identifyI prefer not to answer

    What is your preferred official language for professional communications? (Please select all that apply)


    Who will be providing payment for your registration fees? (Please choose one answer)


    Please provide the contact details of the person who should be contacted regarding payment of your registration fees.

    Dates of training session for which you want to register

    How did you hear about the BETTER Prevention Practitioner Training Institute? (Please choose all the answers that apply)

    BETTER advertisement (i.e. in a newsletter)BETTER Program websiteColleagueEmployerMedia (i.e. local paper, commercial, radio, etc.)Presentation/conferenceOther