203 college street, suite 402, toronto, ontario M5T 1P9

2014 - 2015Membership Application Form
Instructions:
  1. Please indicate your budget category in the table to the left, the matching Membership Fee is the payment owing for the 2014-15 membership year.
  1. Review and update your contact information in the table below, e-mail the completed form to to confirm your membership.
  1. Mail completed form and cheque payable to:
Association of Family Health Teams of Ontario
60 St Clair Avenue East, Suite 800
Toronto, Ontario, M4T 1N5 / BUDGET CATEGORY / MEMBERSHIP FEE / INDICATE CATEGORY
Less than $1M / $2,000 / ☐ /
$1M - $2M / $2,250 / ☐ /
$2M - $3M / $2,900 / ☐ /
$3M - $5M / $3,600 / ☐ /
$5M - $7M / $5,000 / ☐ /
Greater than $7M / $6,000 / ☐ /
2014-15 MEMBERSHIP FEE / Click here to enter text. /
Name of Primary Care Organization
Team Name / Click here to enter text. /
Coordinates (if multi- site, please give administrative office)
Street Address / Postal Code / Phone Number / Fax Number
Update / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Organization Characteristics
# of rostered/registered patients / Total # of patients (if larger than roster) / Designated as “Academic”?
(Y/N) / Governance Type
provider (P)/
community (C)/
mixed (M) /
under governance of another organization (Other) / EMR(s) in use
Update / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Contacts
Medical/Clinical Director / Executive Director / Administrative Lead / Chair
Name / E-mail / Name / E-mail / Phone # / Name / E-mail
Update / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Additional Contacts to receive AFHTO e-mails (optional)
Name / E-mail / Name / E-mail / Name / E-mail
Update / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Please direct all comments, questions or concerns to or by phone at 647-234-8605
Questions? / / 647-AFHTO-05(647-234-8605)