Clinical Educator Recognition Program Online Application Form

  • Please fill out this form and submit once you have attained a level of student supervision.
    We'll verify everything and be back in touch!

    Yearly deadlines for application submissions are:
    March draw deadline: March 1st (Draw on March 31st)
    October draw deadline: October 1st (Draw on October 31st)

    Please note: If you do not have all or some of your student names from past placements you will still be able to submit an application. In this case, however, we require your Site Coordinator or Clinic Owner/Manager to verify placement information, therefore you must send in a paper application with applicable signature, rather than apply online. The link to the paper application form can be found on the Clinical Educator Recognition Program information page.

  • If you hold current membership to the PABC please provide your membership number.
    Note: The winner of the Royal (800 point) level will need to have/obtain CPA membership in order to receive the 1-yr paid PABC membership.
  • Please choose the level you are applying for.
  • Eligible years, per level, for 2017 draws

    Cobalt: 2017, 2016, 2015
    Sapphire: 2017, 2016, 2015, 2014, 2013
    Royal: 2017, 2016, 2015, 2014, 2013, 2012, 2011, 2010
  • Add one line per student. (Click on the "+" to add more lines.) Please list in chronological order, starting with the most recent student.

    If you supervised more than one student at a time write each student’s name on a separate line, and under the “Points” column please show the placement ratio (e.g., 2:1). Beside the name of the LAST student in that placement ratio grouping, show the total points for that group of students (e.g., 2:1 = 200).

    Can't remember which placement level it was? You will find our current three cohorts' placement dates under the tab Clinical Educators » Resources For Clinical Sites & Educators » UBC MPT Program Clinical Placement Dates on our website.

    Did you supervise a non-UBC MPT student (Canadian or International)? If yes Please indicate INTL (for international) or OOP (for out-of-province) as the placement level, and indicate the year, e.g., OOP/2015.
    Student Name (first/last)Facility where supervisedPointsPlacement level/Year (e.g., 1A / 2012) 
    Add a new row
  • Would you like to receive a certificate of recognition from us?
    If yes, please fill out your address information, below.
  • Please give us the address where you would like your certificate mailed.