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Registration form |
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Please print & complete this registration form. (2 pages) Please print clearly. |
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6th Annual risk and recovery forensic conference |
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REGISTRATION INFORMATION |
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To register payment must accompany the registration form upon submission.
If paying by credit card, please fax the completed registration form to our confidential fax at 905-381-5605.
If paying by cheque, please mail registration form and payment to: Josie Cosco Coordinator for the Risk & Recovery Forensic Conference St. Joseph’s Healthcare Hamilton Forensic Outpatient Department West 5th Campus 100 West 5th Street Hamilton, ON L8N 3K7 Cheques can be made payable to St. Joseph’s Healthcare Hamilton.
** We will send an email confirming the receipt of your registration form. |
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FEES & OPTIONS For more information on the options, please go to the “Conference” page
Early Bird Rate (before February 29, 2012) ¨ Registration Fee $385 pp ¨ Group Rate (5 or more reg.) $325 pp ¨ Student / Resident Fee $285 pp
Registration Rate (after March 1, 2012) ¨ Registration Fee $425 pp ¨ Group Rate (5 or more reg.) $365 pp ¨ Student / Resident Fee $325 pp
Vineland Estates Wine Tour & Dinner Please call or email Josie to register for this option 905-522-1155 ext 35415 jcosco@stjoes.ca |
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Thursday April 12, 2012 Morning Symposia: ¨ Dr. Caroline Logan ¨ Ms. Maria Reitmeier ¨ Dr. Sandy Simpson ¨ Dr. Philip Klassen ¨ Dr. Johannes Zeidler |
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First Name: ____________________Last Name:__________________________ Title/Position:____________________________________________________ Organization:_____________________________________________________ Mailing Address:___________________________________________________ City: _____________________ Province: ________ Postal Code:______________ Phone: ____________________________Fax: __________________________
*** Email:_______________________________________________________
** Email is used to send receipts and any updated information. |
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PLEASE MAKE YOUR SELECTIONS BELOW Select one box from each section |
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Friday April 13, 2012 Morning Symposia: ¨ Dr. Paul Fedoroff ¨ Ms. Susan McGowan & Dr. Heather Moulden ¨ Mr. Marc Woodbury-Smith ¨ Mr. Thomas Horn, Brandon Sunstrum & Daniel Kirilo ¨ Dr. Gary Chaimowitz, Christina Oliveria-Picado, Maria Reitmeier and Anne MacPherson
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Friday April 13, 2012 Afternoon Symposia: ¨ Mr. Wayne Skinner ¨ Dr. Elissa Ball ¨ Ms. Mary-Lou Martin, Mary Griffiths, Yasir Rehman & Coralie Hecker ¨ Dr. Susan Farrell
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Option 1 $125 pp Risk Assessment Workshop Presented by Dr. Chaimowitz & Dr. Mamak Wednesday April 11 at 2:00 p.m. West Ballroom, Sheraton Hotel
Option 2 $125 pp Risk and Recovery Workshop Presented by Dr. C. Logan Wednesday April 11 at 2:00 p.m. South Ballroom, Sheraton Hotel
Option 3 $45 pp Dinner & Networking Opportunity Thursday April 12 at 6:00 p.m. Acclamation Restaurant Select one entrée: ¨ Chicken Supreme ¨ Tilapia ¨ Beef Tenderloin |
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TOTAL CHARGE: $_______ (include registration rate + Options if selected) |
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Thursday April 12, 2012 Afternoon — Keynote Speakers *please see the itinerary for further information* |
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PAYMENT INFORMATION
Payment by ____ CREDIT CARD ____ CHEQUE
Credit Card: ___ Visa ___ MasterCard ___ American Express
Credit Card #:___________________________________________________
Expiry Date: ____________________________________________________
Name on Credit Card: ______________________________________________
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