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About
Team-Based Primary Care
Advocacy & Policy
Programs & Resources
News & Events

Membership Application Web Form

For organizations interested in becoming a member of the Association of Family Health Teams of Ontario.

Membership Application Web Form

For organizations interested in becoming a member of the Association of Family Health Teams of Ontario.

Please complete all sections and click submit.

Fields marked with * are required.

1. Member User Fields

Administrative

Legal Organization Name *

Organization Name

Admin Office Address *

Phone Number *

Fax Number

Communications and Social Media

Website

Linkedin

X

Facebook

Instagram

Other

Budget and Finances

Select your annual operational budget category *

What are the top sources of funding/revenue for your organization (include up to three)?

Source 1 *

Source 2

Source 3

I confirm that our primary source of funding is the Province of Ontario. * Yes No

2. Primary Contacts

Primary Contacts

Current Most Senior Executive (e.g. Executive Director, CEO)

First Name

Last Name

Job Title

Email

Phone

Physician/Nurse Practitioner Lead

First Name

Last Name

Job Title

Email

Phone

Operations/Admin Contact (for membership matters)

First Name

Last Name

Job Title

Email

Phone

Billing Contact

First Name

Last Name

Job Title

Email

Phone

Board Chair

First Name

Last Name

Job Title

Email

Phone

Application Contact

Name

Email

Title

3. Organization Characteristics

Team Composition

Type of Interprofessional Primary Health Care Team

Other Interprofessional

Which Ontario Health Team is your organization affiliated with?

Affiliate 1

Affiliate 2

Affiliate 3

Affiliate 4

Current number of Family Physicians (Can include target if not at full capacity yet)

Current number of Nurse Practitioners (Can include target if not at full capacity yet)

Interprofessional team disciplines

Family Physician

Nurse Practitioner

Registered Nurse

Registered Practical Nurse

Physician Assistant

Social Worker

Traditional Healer

Registered Dietitian

Pharmacist

Physiotherapist

Occupational Therapist

Respiratory Therapist

Health Promoter

Kinesiologist

Clinical Psychologist

Psychotherapist

Care/System Navigator

Chiropodist

Other

Other Disciplines

Patient Attachment

Number of rostered/registered patients

Total number of patients served, if larger than roster

Additional Details

Funding model

Other Funding Model

Number of clinics/locations

Non-profit status

Independent

Incorporated under another organization

No Non-profit Status

Do you have a charity status? Yes No

4. Consents

We meet AFHTO eligibility criteria *

We agree to pay the membership fee required to join the Association of Family Health Teams of Ontario. *

The information provided herein is true, complete, and accurate. *

We consent to receive electronic communications from Association of Family Health Teams of Ontario related to membership, events, and programs. *

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