Primary Care Support Grant Application

Personal and contact information

Applicant name(Required)

First Last

Email address(Required)

Email address Confirm email address

Phone number(Required)

Are you applying as an individual or an organization?(Required)

Individual

Organization committing to offering services

Start date for practicing in Beaumont

This date must be within one year of submitting the application.

Type of practitioner(Required)

General practitioner / Family physician

Nurse practitioner

Student general practitioner

Student nurse practitioner

Which regulatory group is the practitioner associated with?(Required)

College of Physicians and Surgeons of Alberta (CPSA)

College of Registered Nurses of Alberta (CRNA)

Neither, yet

Registration number(Required)

Please provide your registration number assigned by your regulatory body.

Have you previously received funding from the City of Beaumont's Primary Care Support Grant?(Required)

Yes

Practice information

Please include the information about the clinic associated with your application.

Clinic name(Required)

Clinic address(Required)

Street address Address line 2 City Postal code

Health service gaps(Required)

Which identified health service gaps will you be able to address through your 2-year practice within Beaumont, in addition to taking on new patients:

After-hours care

Walk-in capacity

Semi-urgent care

Virtual care

Other

Other service gaps(Required)

Service gap plan(Required)

Describe how you will enhance or add new services to address the gaps identified in the previous question.

Contract and supporting documentation(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 20 MB, Max. files: 5.

Please attach the contract (either with the employing clinic or with the additional primary care practitioner your clinic is employing). This contract should indicate an employment term of at least two years. You may also upload other supporting documentation for your application.

The personal information collected is authorized under Section 4(c) of the Protection of Privacy Act and is managed in accordance with the Act. It will be used to assess eligibility, process the grant application, administer funding and for program planning and evaluation purposes. Information will be kept confidential and shared only with individuals involved in the review and administration of the grant. If you have questions about the collection or use of your personal information, please contact the Privacy Officer at 780-929-8782.

Program registration

Primary Care Support Grant Application

Personal and contact information

Practice information