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NOTE: Applications will be reviewed by the Executive Committee for one of the following eligible criteria as below:

Full membership – MAC members: The individual should be competent to recruit patients, contribute high quality data to MAC and lead research studies using the data in MAC.

Associate MAC members: Genetic counsellors and other professionals who work with a good Aortopathy program, involved in clinical appraisal and patient follow up and liaison with clinicians looking after the patients. Associate members can move into full membership if they input high quality data and take the leadership in doing so. A letter in support of full membership will be required for the committee’s approval.

    MEMBER INFORMATION

    REQUIRED *

    Contact MACaorta@gadacanada.ca if you need assistance

    First Name (*)

    Middle Name

    Last Name (*)

    Suffix

    Degree(s)

    Sex FemaleMale

    Year of Birth

    APPLICATION GUIDELINES:
    Please fill out the application form and attach your current CV for approval by the MAC steering comittee. You will receive an e-mail from the MAC admin office informing you of the status of your membership application within 7-10 days. Please upload your CV here:

    I have uploaded my current CV.*

    Please also submit a personal statement (addressing the main reason for your application and your planned contribution) Please upload your statement here:

    I have uploaded my personal statement.*

    ADDRESS

    Department (*)

    Institution (*)

    Street (*)

    Mail Stop

    City (*)

    US ONLY

    State

    ZIP

    NON-US ONLY

    Province

    Postcode

    Country or Region  

    Telephone

    Fax

    Your Email (*)

    Website

    I DO NOT wish to receive commercial mailings.

    DEMOGRAPHIC INFORMATION

    Completion of this section is optional. However, your responses will help the MAC Board plan future activities and better represent members’ interests. Even if you have previously answered these questions, we ask that you take a moment to provide your current information.

    PRIMARY AFFILIATION (Select one)

    GeneticsPathologyMedicineRepro. Medicine

    Family MedicinePediatricsPsychiatry/PsychologyOB/GynNeurologyInternal Medicine

    Hospitals and ClinicsDental SchoolsCollege/UniversityVetinary SchoolCommercial CompanyFederal GovernmentRetiredOptometry

    HMOPublic Health / Grad SchoolNursing SchoolPrivate PracticeInstitutes / FoundationsState / Local GovernmentConsultantOther

    EARNED DEGREES (Select up to four)

    MDPhDMSWDVMSCD

    DDS or DMDEDDMSMAMSN

    JDMPHRNBSNBS or BA

    DOODMD/PhDOTHER

    ACADEMIC RANK (Select one)

    ProfessorAssociate ProfessorAssistant Professor InstructorNonfaculty

    POSITION (Select up to two)

    DeanDepartment ChairDivision ChiefInstitute Center DirectorLaboratory DirectorTraining Program Director

    Research Program DirectorProgram Coordinator/AdministratorSenior Research AssociateResearch AssociateResearch AssistantGenetic Counselor

    Postdoctoral Research FellowPostdoctoral Clinical FellowResidentGraduate StudentPrivate PracticeCorporate Executive

    ConsultantPrincipal Investigator/ProfessorUndergraduateOther

    MAJOR TYPE OF WORK (Select one that accounts for more than 50% of your time)

    ResearchTeachingAdministrationClinicalCounseling

    SECONDARY TYPE OF WORK (Select one if it represents a significant portion of your time and is different to your major type of work)

    ResearchTeachingAdminisrationClinicalCounseling

    LABORATORY SETTING (If you are primarily in a laboratory setting, indicate focus)

    Private diagnostic/reference labPrivate research labUniv-affiliated diagnostic/reference labUniv-affiliated research labGovernment-affiliated research lab

    SPECIAL INTEREST AREAS (Select up to four)

    Cancer GeneticsCytogeneticsDNA forensicsDifferentiation & developmentDysmorphologyEthics/social/legal/policy issues

    Gene structure & functionInborn errors/biochemical geneticsLate onset/adult genetic disordersLinkage mapping & polymorphismsMolecular geneticsPediatric genetics

    Physical mappingPopulation genetics/epidemiologyPrenatal/perinatal geneticsGenomicsModel systemsInformatics

    Neurogenetics/behavioral geneticsPublic health geneticsEducationPolicy/AdvocacyEvolution

    CURRENT GRANT SUPPORT (Select all that apply - US and Canadian members only)

    NSF (NSERC in Canada)NIH (CIHR) training grantPrivate IndustryNIH (CIHR in Canada)

    Postdoc fellowshipPrivate foundation/charityStateProvince

    InstitutionalOther national agenciesHHMIMRC

    Wellcome

    DESIGNATION(S) FOR YOUR RESEARCH (Select all that apply)

    Applied clinical researchApplied lab researchApplied mathematical researchBasic clinical research

    Basic lab researchBasic mathematical researchELSI/eduation/policyOther

    DONATIONS

    A DONATION TO MAC MAKES A DIFFERENCE
    MAC is administered by GADA Canada, a nonprofit organization, therefore, contributions are tax deductible to the extent permitted by law. Please click here to donate to MAC.

    Please review this form for completeness and accuracy before submitting it.