MEMBERSHIP REGISTRATION 2014/2015 Membership Year Commences October 1 (fees are not pro-rated)

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1 MEMBERSHIP REGISTRATION 14/15 Please complete all information on this form. u Print information clearly. u Sign the completed membership registration form before returning it to CAOT. u Our membership database program gives us several ways to contact you. u Please provide your home address even though it may not be your primary mailing address. u Specify the address you prefer for mailing. You are eligible to join CAOT as an individual member if you meet the following requirements: 1. You are a Canadian citizen or have established your primary residency in Canada; AND a. You have successfully completed the National Occupational Therapy Certification Examination (NOTCE); OR b. You are or have been registered, without restrictions, with a Canadian occupational therapy regulatory body. If you are writing the NOTCE within one year, you are also eligible to fill out this form. You will be considered a Provisional Associate until the successful completion of the NOTCE, at which time you will become a full Member. Date of Birth Month Day Year Gender Language Preference Male Female English French Home Address: Preferred mailing address First Name Middle Name Last Name Address City Province Postal Code Country Telephone Business Address: Employer Preferred mailing address Address City Province Postal Code Country Telephone Page 1 of 4

2 MEMBERSHIP REGISTRATION 14/15 MEMBERSHIP REGISTRATION INSTRUCTIONS 1. Check off all options that apply to you. 2. Consult the schedule on page 3 of this form to determine the appropriate membership fee and applicable taxes. 3. Review and include the fees and applicable taxes for any additional options you have selected (Professional Liability Insurance, Member and Associate Assistance Program (MAAP), World Federation of (WFOT), Canadian Journal of Occupational Therapy (CJOT) and Canadian Occupational Therapy Foundation (COTF) Donation). 4. Enter the appropriate amounts below. 5. Calculate the total amount payable and select your method of payment. FIRST-YEAR CAOT MEMBERSHIP FEE. Available to first-time members. Please note: If you live in BC, first-year member rates for CAOT-BC apply. GST/HST ON MEMBERSHIP FEE See page 3 to determine the amount payable. CAOT PROFESSIONAL LIABILITY INSURANCE PREMIUMS (optional) CAOT members are eligible to purchase Professional Liability Insurance at competitive rates. The insurance packages offered by CAOT meet the requirements of all Canadian regulatory bodies. See page 3 for additional details. OPTION 1. Professional Liability Insurance (Basic) ($5,000,000), Legal Expenses ($150,000) and Criminal Defense ($175,000) Individuals who graduated in 14 are eligible for a 50% discount. $29.50 Individuals who graduated in 13 are eligible for a 25% discount. $44.25 Individuals who are or will be on maternity/parental leave for 6 or more consecutive months between October 1, 14 and September, 15 are eligible for a 50% discount. $29.50 All others. $59.00 OPTION 2. Professional Liability Insurance (Basic) ($,000,000), Legal Expenses ($0,000) and Criminal Defense ($250,000) Individuals who graduated in 14 are eligible for a 50% discount. $48.50 Individuals who graduated in 13 are eligible for a 25% discount. $72.75 Individuals who are or will be on maternity/parental leave for 6 or more consecutive months between October 1, 14 and September, 15 are eligible for a 50% discount. $48.50 All others. $97.00 PST ON PROFESSSIONAL LIABILITY INSURANCE Manitoba, Ontario and Quebec See page 3 to determine the amount payable. MAAP MEMBER AND ASSOCIATE ASSISTANCE PROGRAM (MAAP) FEE (optional) - CAOT s upgraded MAAP will give you even greater value! It includes access of up to 12 hours of counselling in numerous areas: financial, work performance, legal, family, elder care, nutrition, and much more. Free educational materials are also available! Please note that this member benefit is only available to members located in Canada. $68.00 GST/HST on MAAP Fee. See page 3 to determine the amount payable. WFOT WORLD FEDERATION OF OCCUPATIONAL THERAPISTS (WFOT) MEMBERSHIP FEE (optional) - As a member of CAOT you are eligible for individual membership with WFOT. For more details on the benefits available to you as a member of WFOT, please see page 3. $.00 GST/HST on WFOT Membership Fee. See page 3 to determine the amount payable. CJOT COTF CANADIAN JOURNAL OF OCCUPATIONAL THERAPY (CJOT) PRINT COPY (optional) - As a member you can request to receive print copies of CJOT by mail. Electronic access to the journal is complimentary. $.00 CANADIAN OCCUPATIONAL THERAPY FOUNDATION (COTF) DONATION (optional) - If you choose to donate to COTF, an official income tax receipt will be issued for amounts of $25.00 or more. I would like to donate to COTF in the amount of: $5.00 $.00 $25.00 $50.00 amount $ TOTAL PAYMENT DUE CAOT GST REG. NO. R07577 PAYMENT OPTIONS Cheque Visa Please make Canadian cheques or money orders payable to CAOT. A fee of $50.00 will be charged on all NSF items. Money Order Pre-Authorized Payment Plan (PAPP) PRE-AUTHORIZED PAYMENT PLAN To participate in the Pre-Authorized Payment Plan you must complete the PAPP Agreement on page 4 send a void cheque from a Canadian bank account MasterCard Account Number Expiry Name on Card Account Number Expiry Signature Page 2 of 4

3 MEMBERSHIP REGISTRATION 14/15 Membership Category Base Fee GST-5% (AB, MB, NT, NU, QC, SK, YT) HST -13% (NB, NL, ON) HST -14% (PE) HST -15% (NS) Outside Canada BC FEE GST-5% (BC) Special First-Year Rate $ $7.13 $18.53 $19.95 $21.38 $ $9.00 If you live in BC, your membership fee is combined and includes both CAOT and CAOT-BC. Refund policy: As stated in the CAOT by-laws, membership fees are non-refundable. PROFESSIONAL LIABILITY INSURANCE PREMIUMS CAOT offers affordable insurance that is valid across Canada. Unlike insurance you may have through your employer, insurance purchased through CAOT is specifically designed to protect your individual interests. Insurance works on a claims-made basis, which means that you must carry insurance at the time a claim is made, regardless of when the incident occurred. Please note that to purchase endorsements or clinic coverage you must purchase Professional Liability Insurance and add these options to this policy. To purchase clinic insurance or for additional details regarding Professional Liability Insurance, please visit our website ( or contact membership services by telephone : (800) or (613) , ext. 221, or membership@caot.ca. PST on insurance Manitoba and Ontario (8%) PST on insurance Quebec (9%) All others Option 1 Professional Liability Insurance (Basic) ($5,000,000), Legal Expenses ($150,000) and Criminal Defense ($175,000). Includes loss of earnings coverage. Individuals who graduated in 14 are eligible for a 50% discount. $29.50 $2.36 $2.66 Individuals who graduated in 13 are eligible for a 25% discount. $44.25 $3.54 $3. Individuals who are or will be on maternity/parental leave for 6 or more consecutive months between October 1, 14 and September, 15 are eligible for a 50% discount. $29.50 $2.36 $2.66 All others. $59.00 $4.72 $5.31 Option 2 Professional Liability Insurance (Basic) ($,000,000), Legal Expenses ($0,000) and Criminal Defense ($250,000). Includes loss of earnings coverage Individuals who graduated in 14 are eligible for a 50% discount. $48.50 $3.88 $4.37 Individuals who graduated in 13 are eligible for a 25% discount. $72.75 $5.82 $6.55 Individuals who are or will be on maternity/parental leave for 6 or more consecutive months between October 1, 14 and September, 15 are eligible for a 50% discount. $48.50 All others $97.00 $3.88 $4.37 $7.76 $8.73 MEMBER AND ASSOCIATE ASSISTANCE PROGRAM (MAAP) Member and Associate Assistance Program (MAAP) FEE $68.00 GST-5% (AB, BC, MB, NT, NU, QC, SK, YT) $3. HST-13% (NB, NL, ON) $8.84 HST-14% (PE) $9.52 HST-15% (NS) $. WORLD FEDERATION OF OCCUPATIONAL THERAPISTS (WFOT) Membership with WFOT includes the following benefits: Access to the Occupational Therapy International Outreach Network (OTION) website, Receipt of the WFOT Bulletin (twice a year - online only). To purchase a hard copy, please visit Receipt of WFOT s E-Newsletter (twice a year) Interaction with occupational therapists internationally and the opportunity to develop international networks Eligible to apply for Research Awards World Federation of If you live outside of Canada, taxes do not apply. FEE $.00 GST-5% (AB, BC, MB, NT, NU, QC, SK, YT) $1.50 HST-13% (NB, NL, ON) $3.90 HST-14% (PE) $4. HST-15% (NS) $4.50 PERIODICALS Occupational Therapy Now, and the Canadian Journal of Occupational Therapy (CJOT) are available in print copy* or online. Please indicate your preference below. If you wish to receive print copies of CJOT please consult the fee below. If you wish to receive complimentary print copies of OT Now, you MUST check the box below. wise, you will have online access only. OT Now: Print copy * Print copies of OT Now are only available to members with a Canadian mailing address. CJOT is available in print copy for the following fee. Members have complimentary electronic access to CJOT at all times through their online accounts. Canadian Journal of Occupational Therapy (CJOT) FEE $.00 Page 3 of 4

4 MEMBERSHIP REGISTRATION 14/15 CITIZENSHIP Please check the appropriate description of your citizenship. Canadian citizen Landed immigrant Hold a work visa for occupational therapy Do not fit into the above categories but would like to join CAOT as an individual member REGISTRATION AB Not registered Province of current registration with occupational therapy regulatory organization (check all that apply): BC MB NB NS NL ON PE QC SK PRE-AUTHORIZED PAYMENT PLAN AGREEMENT Staple VOID Canadian Cheque Here TERMS AND CONDITIONS - PRE-AUTHORIZED PAYMENT PLAN AGREEMENT IS AVAILABLE THROUGH CANADIAN BANK ACCOUNTS ONLY I authorize the payee to debit my account as indicated on the attached void cheque under the terms and conditions agreed to by me with the payee until March 1, 15. I acknowledge that delivery of my authorization to the payee constitutes delivery by me to the branch of the financial institution at which I maintain an account and that the payments are drawn in accordance with this authorization. Termination of this authorization does/ may not terminate the contract for goods or services exchanged. I will notify the payee in writing of any changes in the account information or termination of this authorization 7 days prior to the next due date of the pre-authorized debit. A sample cancellation form and further information about your right to cancel a PAPP Agreement may be obtained at your financial institution or by visiting the CPA s website at I understand that my monthly payments are calculated by dividing the total dues payable by the number of months remaining in the payment plan year up to and including March 1, 15. You have certain rights if any debit does not comply with this agreement. For example you have the right to receive reimbursement for any PAPP that is not authorized or is not consistent with the terms of this PAPP Agreement. To obtain more information on your recourse rights, contact your financial institution or visit I warrant that all persons whose signatures are requested to sign on this account have signed this agreement. EXAMPLE PAPP CALCULATION: FIRST-YEAR CAOT FEES PLUS PROFESSIONAL LIABILITY INSURANCE COVERAGE OPTION 1 Received before October 1 Total fees due $ Insurance (Option 1) $59.00 Total due $1.50 Number of months 6 Monthly payment $33.58 If your response is received on Nov. (2 missed payments) Total fees due $ Insurance (Option 1) $59.00 Total due $1.50 Number of months 4 Monthly payment $50.38 I (we) authorize The Canadian Association of Occupational Therapists to process a debit, in paper, electronic or other form in the amount of $ on my (our) account on October 15, 14 and on the 1 st day of each month, beginning November 1, 14 and ending March 1, 15, the end of the payment plan year. I understand that the payment plan is based on 6 equal payments only if my renewal, PAPP and sample voided cheque have been received at the CAOT office on or before October 1, 14. If in any month there has been a missed payment due to insufficient funds, I understand that CAOT reserves the right to process the remaining balance plus the $50.00 NSF charge, in equal amounts over the number of payments remaining in the plan. CAOT reserves the right to change the withdrawal amount if there is an error in calculation and will provide written notice to me of the changed payment withdrawal amount. I acknowledge that I have read and understand all the provisions contained in the terms and conditions of the pre-authorized payment authorization. A fee of $50.00 will be charged on all NSF items. Signature Date SIGNATURE REQUIRED. Completed and signed form must accompany payment. Signature indicates agreement to abide by CAOT By-laws and Code of Ethics (available from and confirms eligibility for membership as indicated on page 1 of this form. Signature Date Page 4 of 4

5 MEMBERSHIP PROFILE SURVEY The following information is requested to ensure a current membership profile. Please complete all sections. Check all applicable boxes according to the instructions in each section. The Association utilizes this information when representing the profession, facilitating networking and appropriate referrals, and for research purposes. It is important that ALL members provide this information upon joining CAOT and update it annually when renewing. DEFINITIONS For more definitions, please check our website. ( PRIMARY EMPLOYMENT The employment, with an employer or in a self-employed arrangement, that is associated with the highest number of usual weekly hours worked. SECONDARY EMPLOYMENT The employment, with an employer or in a self-employed arrangement, that is associated with the second highest number of usual weekly hours worked. TERTIARY EMPLOYMENT The employment, with an employer or in a self-employed arrangement, that is associated with the third highest number of usual weekly hours worked. REFERRALS/RELEASE OF INFORMATION I consent to the receipt of communications, as well as the publication/communication of my name, employer(s), contact address(es), address and telephone number(s) to third parties for the purpose of communication/solicitation by such third parties, or as a professional resource for the following purposes: Listing on OT Finder on YES NO Recruitment Mailings Product Advertising Mailings Canadian Occupational Therapy Foundation (COTF) Client Referrals/Consulting Education and Public Relations Professional Networking Research Survey Legal Referrals Listing on OT Networker on Listing on OT Researcher on Note: Statistical information for members in the Territories will be shared with the Canadian Institute for Health Information (CIHI) for the purposes of health human resources planning. * You must be registered with your regulatory body to be listed (except members in Territories) and you must have a city and province listed in the business address section. Do not appear Private Practice Publicly Funded Appear as both Private Practice and Publicly Funded Please check all services provided: Adaptations Advocacy Aging/healthy aging/aging in place Assistive technology Brain injury rehabilitation Caregiver support/education Case management Cognitive/perceptual assessment and interventions Counselling Services Dementia care Driver rehabilitation assessments Dysphagia Education Equipment Ergonomics Extended/long term/ residential care Functional capacity Generalist Hand therapy/splinting Home assessments and modifications Housing/urban planning Insurance assessments Learning disability Management consulting Medical/legal related client service mgmt Mental health and addictions Musculoskeletal Neurology Orthopaedics/prosthetics Pain management Physical rehabilitation Policy Population based health Research Scar management/burn care School based care Seating Sensory integration Spinal cord injury Stress management Stroke rehabilitation Teaching/education/training programs Vehicle modification Vocational rehabilitation Wheelchair/seating Worksite assessments and intervention ACADEMIC ACHIEVEMENTS/PURSUITS Indicate one 2 digit code in the boxes provided for the three highest degrees that you have obtained in your academic history. OCCUPATIONAL THERAPY - Level of Education Certificate/Diploma Baccalaureate Unspecified Master s 31 Professional Master s 32 Research Master s Doctorate OTHER THAN OCCUPATIONAL THERAPY - Level of Education Major Field Basic Education School Year obtained Country Level of Post-Basic Education School Year obtained Country Level of Post-Basic Education School Year obtained Country School Year obtained Province Country School Year obtained Province Country School Year obtained Province Country Level of Education Diploma Baccalaureate Master s Doctorate Major Field Indicate one 3 digit code in the boxes provided that best represents your major field of study General Rehabilitation Science 060 Gerontology 1 Education Health Administration/Management 070 Psychology 1 Law Public Administration 080 Health Professions and Related Clinical Sciences 1 Business Management, Marketing and Related Epidemiology/Public Health 090 Biological, Biomedical and Physical Sciences 1 Field of Study Kinesiology and Exercise Science 0 Social Sciences, Arts and Humanities 8 9 Page 1 of 3

6 EMPLOYMENT CATEGORY Indicate one 2 digit code for each employment type. 11 Permanent Employed, on leave Temporary Casual Self-Employed POSITION/ROLE Indicate one 2 digit code for each employment type. Manager Educator 50 Professional Leader/Coordinator Researcher # hours worked/wk # hours worked/wk # hours worked/wk Direct Service Provider PERSONAL EARNINGS What are your average hourly earnings? [Gross annual income/hours worked in a year. This will likely be different from your billing rate (for statistical purposes only).] $0-$19/hour $26-$/hour $36-$/hour Over $50/hour $-$25/hour $31-$35/hour $41-$50/hour 60 MEMBERSHIP PROFILE SURVEY FULL-TIME/PART-TIME STATUS Indicate one 2 digit code for each employment type. Full-time Part-time PROV/TERRITORY/COUNTRY OF EMPLOYMENT Prov./Terr. Postal Code Country Prov./Terr. Postal Code Country Prov./Terr. Postal Code Country SERVICES Please indicate the 3 digit code in the boxes provided for the areas that best reflect your work, in your PRIMARY EMPLOYMENT, in order of importance, listing the most important service first. Also indicate the service where you undertake RESEARCH and where you use SUPPORT PERSONNEL. Primary service Secondary service Tertiary service Research Support personnel SERVICES -Client SERVICES - Professional Issues Alternative therapies Assistive technology Behaviour therapy Caregiver support/education Case management Chronic pain management Client education Community development Consulting Cognitive/Perceptual Therapy Counselling/Supportive Therapy Crisis/Emergency Service Dementia Driver evaluation and training Eating Disorders Ergonomics Medical/Legal Feeding/Swallowing Forensic/Correctional Services Functional mobility Hand rehabilitation HIV/AIDS rehabilitation Home care Independent living Leadership training Neonatology Neurodevelopmental treatment Occupational life skills Primary Health Care Orthotics Prosthetics Seating Sensory integration Substances and Addictions Stress management Universal design Workplace health Advocacy Ethics Occupational theory/philosophy Occupational therapy education Research utilization SERVICES - Program Leadership/ Administration Continuous quality improvement Policy development Planning Program coordination/management Program evaluation FUNDING FOR YOUR PRACTICE Please select one 2 digit code in the boxes provided indicating the funding source for each employment type. CLIENT AGES Please select one 2 digit code in the boxes provided indicating client ages for each employment type. Public/Government Client(s) or Private Sector Public/Private Mix Funding Source 21 Preschool Age (< 4 yrs) School Age (4-17 yrs) Mixed children (0-17 yrs) Adults (18-64 yrs) Seniors (65 yrs) Mixed adults (18 yrs) All AREA OF PRACTICE Please select one 3 digit code in the boxes provided that best describes your area of practice for each employment type. PHYSICAL HEALTH SYSTEMS ADDITIONAL AREAS OF DIRECT SERVICE AREAS OF CLIENT MANAGEMENT EDUCATION OTHER 0 Mental Health 060 General Physical Health 1 Client Service Management 1 Teacher 8 0 Neurological/Neuromuscular 070 Vocational Rehabilitation 1 Medical/Legal Related Client 9 0 Musculoskeletal 080 Palliative/End of Life Care Service Mgmt ADMINISTRATION 0 Cardiovascular & Respiratory 090 Health Promotion and Wellness Service Administration RESEARCH Digestive/Metabolic/Endocrine 0 Areas of Direct Service Provision 150 Area of Practice Research 160 Page 2 of 3

7 MEMBERSHIP PROFILE SURVEY EMPLOYER TYPE Please select one 3 digit code in the boxes provided that best describes your practices settings for each employment type General Hospital Rehabilitation Hospital / Facility Mental Health Hospital / Facility Residential Care Facility Assisted Living Residence Community Health Centre Visiting Agency/Business Group Professional Practice/Clinic Solo Professional Practice/Clinic Post-secondary Education Institution School or School Board Assoc./Gov t/para-gov t Industry, Manufacturing and Commercial -Employer Type not Described OCCUPATIONAL PERFORMANCE ISSUES Please indicate one 2 digit code in the boxes provided for the main occupational performance components and environmental conditions faced by your clients for each employment type. Primary Employment Secondary Employment Tertiary Employment PERFORMANCE COMPONENT Affective (e.g. social, emotional functions) Spiritual (e.g. essence of self, motivation, personal control) Cognitive (e.g. perception, memory, judgement, intellectual) Physical (e.g. sensory, motor function) ENVIRONMENTAL CONDITIONS Cultural (e.g. adaptation) Social (e.g. family) Institutional (e.g. educational, housing) Physical (e.g. accessibility, transportation) SUPPORT PERSONNEL Do you assign components of occupational therapy service to occupational therapy support personnel* in your PRIMARY employment? Check all that apply: (* refers to persons who are not qualified occupational therapists but are knowledgeable in the field of occupational therapy and are directly involved in the provision of occupational therapy services under the supervision of an occupational therapist.) I assign service components to support personnel that have been formally trained I assign service components to support personnel with other training for the provision of support services to occupational therapists I do not assign service components to support personnel FUNCTIONS OF SUPPORT PERSONNEL Please select the type of service components performed by SUPPORT PERSONNEL to ASSIST you in your primary employment. Office administration (e.g. intake referrals) Client assessment Client intervention/education Management of equipment/supplies Program planning and evaluation (e.g. data collection, workload measurement) VOLUNTEERING For more volunteer opportunities, visit Would you be willing to have your name appear on the OT Mentor ( as a potential mentor for other occupational therapists? Yes* No, not at this time * You must also consent to listing on OT Networker on page 1 (See: Referrals/Release of Information section). LANGUAGE Language(s) spoken: English French Language(s) written: English French Page 3 of 3