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Registration Form |
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Please print & complete this registration form. Please print clearly. |
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REGISTRATION INFORMATION |
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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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Payment by: ____ CREDIT CARD ____ CHEQUE
Credit Card: ___ Visa ___ MasterCard ___ American Express
Credit Card #:___________________________________________________________________
CVV:___________________ Expiry Date:_____________________________
Name on Credit Card: ____________________________________________________________ |
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Registration Rate ¨ Registration Fee $425 ¨ Group Rate (5 or more reg.) $365 ¨ Student / Resident Rate $325 |
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q Pre-conference Workshop $225 Wednesday, April 24 at 8:30 am q Forensic Psychiatry Review Course $225 Wednesday, April 24 at 8:30 am q Art Gallery Tour & Dinner $60 Thursday, April 25 at 5:00 pm |
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TOTAL CHARGE: $_______ (include registration rate + options if selected) |
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SYMPOSIA SELECTIONS Select one box from each section |
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Thursday April 25, 2013 Afternoon — Keynote Speakers *please see the itinerary for further information* |
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Payment must accompany registration form.
If paying by credit card, please fax the completed registration form to our confidential fax at 905-381-5605 or mail to the address below. Cheques payable to St. Joseph’s Healthcare Hamilton and mailed with form to:
Josie Cosco Risk & Recovery Forensic Conference St. Joseph’s Healthcare Hamilton West 5th Campus,100 West 5th Street Hamilton, ON L8N 3K7
** We will send an email confirming the receipt of your registration form. |
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Friday April 26, 2013 Morning Symposia:
¨ Dr. Jeffrey Abracen ¨ Dr. Janelle Hawes & Dr. Catherine Krasnik ¨ Dr. Tonia Nicholls ¨ Dr. James Ogloff ¨ Sarah Burtenshaw |
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Thursday April 25, 2013 Morning Symposia:
¨ Dr. John Bradford ¨ Dr. Carol Vipari ¨ Dr. Margaret McKinnon ¨ Maria Reitmeier & Anne MacPherson |
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Friday April 26, 2013 Afternoon Symposia: ¨ Dr. Heather Moulden & Hillary Jones ¨ Dr. Candice Monson ¨ Dr. Mini Mamak & Dr. Gary Chaimowitz ¨ Mary-Lou Martin |
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PAYMENT INFORMATION |
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FEES & OPTIONS |
