GEMS Application Form

Consent to Collect, Use and Disclose Personal Information

The terms of this consent agreement govern the collection, use and disclosure of your personal information which you submit to the Alberta Rural Physicians Action Plan, operating as Alberta's Rural Health Professions Action Plan ("RhPAP").

The Purpose of Collection, Use and Disclosure

RhPAP may collect, use and disclose your personal information for the purposes of providing and administering the General Emergency Medicine Skills ("GEMS") Course, including (without limitation):

1. Determining your eligibility for GEMS and


2. Administering GEMS.

Personal Information Subject to Consent

Your personal information that will be collected, used, and disclosed by RhPAP for the purposes of providing and administering GEMS includes:

1. Demographic information, including name, mailing address, email, and phone number;


2. Professional information; and


3. Education history

Withdrawal of Consent

You may withdraw or vary the terms of your consent in writing or electronically at any time. However, RhPAP may be unable to process your application for GEMS in the event that you withdraw or vary the terms of your consent. RhPAP reserves the right to refuse to process your application in such an event.