BCCA Membership Intake Form

Please complete the following information to submit your application for BCCA membership.

Fields marked in red with an asterisk are required. Wherever you see a question mark icon (), you can click it for more information.

Your personal information
Title:
Type your title:
First name:
Last name:
Middle name(s):
Preferred name:
If different from your legal name, above.
Gender:
   
Date of birth:
The following information is voluntary and is collected in order to help patients find you if you have changed names and they have called us unable to find you. It is not displayed publicly and is for BCCA use only.
Former legal last name:
Former legal first name:
Your BCCA membership status
Please choose the option that best matches your current registration status.

If you are in the process of setting up your practice or moving to BC from another province, choose the option that will apply when you are done.

Please enter the name of the licensing body that governs your primary practice:
When do you anticipate starting your practice in BC?
What is your anticipated start date?
CCBC registration date:
(if known)
Current CCBC status:
  If you are in the process of applying, choose the status you are applying for.
MSP number:
  If you are a new grad or recent transfer and do not have this yet, you may leave it blank
Your education and practice
Chiropractic school:
Expected grad date:
Grad date:
Are you incorporated?
 
How many hours a week do you currently practise chiropractic?
Your contact information
Email address:
Daytime phone:
Cell/home phone:
Mailing address:
Country:
Street:

City:
Province:
Postal code:
Student survey
In which province do you plan on practising?
What are you most concerned about with respect to starting your career?
How did you hear about us?
Consent
I consent to receiving email communications from the BC Chiropractic Association, these will include, but not be limited to, our Monday Morning Memo e-newsletter and other important communications related to your membership. We strive to keep the amount of email you receive from us consistent (1/week) and to keep additional email volumes low. You can withdraw your consent at any time by clicking unsubscribe on our emails or by emailing BCCA@bcchiro.com. Please note the BCCA communicates with its members primarily through email.
Please indicate your consent:    
I consent for BCCA to communicate with third parties such as (but not limited to): College of Chiropractors of BC, Canadian Chiropractic Association and Canadian Chiropractic Protective Association, with respect to my membership/registration.
Please indicate your consent:    
Your clinic locations

Please add all clinics at which you practise, below. One clinic should be designated as your primary location. If you are retired from active practise, you do not need to list any clinics. Click "Remove clinic" for any clinics at which you no longer practise.

Your public listing profile
Drop your new profile image file here
File upload progress:

Use the preferences below to control how, and whether, your information will be shown in the Find-a-Chiro tool on the Association web site. Only clinics in BC are shown.

For the social media account options, you may enter your username on the service if you wish a link to be displayed with your listing.

Display preferences:
Your email will never be publicly shown, but an email can be sent via a contact form unless you check this box
Profile image:
You may upload a photo to display on your profile page. Select the image below, or drag and drop it onto the space to the right, to upload.
Are you comfortable speaking with patients in any languages other than English? Please check any that apply below.
Do you speak any language not listed above? Let us know and we'll add it to our list!
Your social media links

Please provide links to any professional social media accounts you maintain. For each social media site, you may choose to have the link displayed on your public profile, or keep it private.

Please leave the field blank if you do not have an account.

Facebook page name:
Navigate to your Facebook page and copy the underlined portion from your web browser's location bar only:
https://www.facebook.com/your_page_name/
Instagram username:
@
Navigate to your Instagram page and copy the underlined portion from your web browser's location bar only:
https://www.instagram.com/your_user_name/
Twitter username:
@
Navigate to your Twitter page and copy the underlined portion from your web browser's location bar only:
https://twitter.com/your_user_name/

Help icons

You can click any question mark (help) icon for more information about that section of the form.

Your date of birth

We use this information to help determine your BCCA membership category.

Using the calendar

  1. Select the year from the drop-down at the top of the calendar.
  2. Use the left and right arrows at the top to choose the month.
  3. Finally, click on the day in the calendar.

After completing these steps, the calendar should close and the proper date should be displayed in YYYY-MM-DD format.

CCBC registration date

Using the calendar

  1. Select the year from the drop-down at the top of the calendar.
  2. Use the left and right arrows at the top to choose the month.
  3. Finally, click on the day in the calendar.

After completing these steps, the calendar should close and the proper date should be displayed in YYYY-MM-DD format.

Your current status with BCCA

This is your current status with BCCA. If your status is changing, this will be reflected on the next page, based on the information you provide on this page.

Voting rights

BCCA members enjoy either voting or non-voting status, which is determined by their registration status in BC. If you are a registrant of the College of Chiropractors of BC you will have voting status in BCCA, if you are not a registrant (expired/deleted, student, or registrant of another jurisdiction) you will be a non-voting BCCA member.

Your graduation date

We use this information to help determine your eligibility for sponsorship. Month is required for any grad date within the past three years. Beyond that, month is optional but recommended.

Incorporation status

We collect this information for reporting and list segmenting purposes.

Your hours of practise per week

We use this information to help determine your BCCA membership category.

Front office email

We use this address to send your staff information such as the Monday Morning Memo in order to help them stay aware of anything relevant to their work in your office.

If you do not wish to receive email communications at your front office email, please leave this field blank.

Please wait while your profile changes are processed. This may take some time, especially if you are uploading a large profile image.