WIRA - Water Incident Research Alliance

Contributing Member
Associate Member
Supporting Member
Patron Member

Note: all information with an asterisk (*) is mandatory.

Contact Information for Port #1
Name *
Title *
Organization name *
Mailing address *
Postal Code *
Phone *
Fax *
E-mail address *
(this will become your user name for logging on to the WIRA Web site)
Membership Information
Is someone in your organization already a WIRA member and you require an additional port, or is your organization joining WIRA for the first time?

How many additional ports do you require? *
If you only require one port, Click here, to skip this part of the form.
* Please list the names and contact information for each additional port (up to 5 port licenses per application)

Additional Port #2
Name *
Title *
Organization name *
Mailing address *
Phone *
Fax *
E-mail address *
(this will become your user name for logging on to the WIRA Web site)
Additional Port #3
Name *
Title *
Organization name *
Mailing address *
Phone *
Fax *
E-mail address *
(this will become your user name for logging on to the WIRA Web site)
Additional Port #4
Name *
Title *
Organization name *
Mailing address *
Phone *
Fax *
E-mail address *
(this will become your user name for logging on to the WIRA Web site)
Additional Port #5
Name *
Title *
Organization name *
Mailing address *
Phone *
Fax *
E-mail address *
(this will become your user name for logging on to the WIRA Web site)

Organizational Information

In what category does your organization belong? Please click beside the category that applies. *

Not-for-profit organization

Federal government department
Provincial government department
Municipal government department
Health unit or agency (regional, county or local)
Aquatic, boating, or recreational organization
Injury prevention foundation, researcher, medical association, hospital association or coroner
International organization
Other (please specify):
Private-sector corporation
Please specify the kind of business you are in (e.g., boating, marine, insurance, consulting, media, etc.)

Private individual
Click this option if you are not using WIRA data as part of a not-for-profit or private sector organization.

Arranging payment
How do you wish to be billed? Please choose one option *


Billing information
Please complete your billing information. If it's the same as what you entered at the top, please click "same as above."
	Same as above
Name *
Title *
Organization name *
Mailing address *
Postal Code *
Phone *
Fax *

I have read and agree to the terms and conditions of the WIRA Member License Agreement.*

I agree
I don't agree/I have questions

If you have questions, e-mail them to us or call us to discuss your concerns.

When do you want to activate your WIRA membership? Memberships are valid for 12 months from the date of activation, renewable on a yearly basis. *

Day / Month / Year

Are there particular kinds of incidents or injuries you are most interested in (i.e., boating fatalities, all deaths and injuries in a particular province or county, incidents occurring in the summer, drownings, major non-fatal injuries, etc.)?

How do you expect to use WIRA data?

How did you hear about WIRA?

Any other questions or comments for WIRA?

Periodically, we send an e-mail newsletter containing valuable updates that will interest WIRA members. Would you like to receive this newsletter?

Yes
No

WIRA Member Application

Membership Categories

Contact Information for Port #1

Membership Information

Additional Port #2

Additional Port #3

Additional Port #4

Additional Port #5

Organizational Information

Arranging payment

Billing information