2014 Geriatrics Update Registration Form

Please indicate your category:

Which day(s) are you attending?   Please select one I am attending Friday Oct 31 only I am attending Saturday Nov 1 only I am attending both days

Contact Information

Your profession  

Organization Name  

Title   Dr. Ms. Mrs. Miss Mr.

First Name  

Last Name  

Mailing Address

Unit, Suite, or Apartment

City  

Province / State

Country

Postal / Zip Code

Business Phone  

Fax

Your E-Mail Address  

Lunch with the Professors

*no extra fee but pre-registration is required; space is limited and will be given on a first-come-first serve basis  

I will NOT be registering for the Lunch with the Professors session

I will be attending one session on Friday October 31 (please fill in session code below; limit ONE session per day per person)

I will be attending one session on Saturday November 1 (please fill in session code below; ONE session per day per person)

Enter session code(s):

* For session codes and description, please click here

Payment Amount

Registration Fees	Fees
Physician (1 day)	$200.00
Physician (both days)	$350.00
Nurses and allied health professionals and trainees (1 day)	$150.00
Nurses and allied health professionals and trainees (both days)	$250.00

  

I will be submitting the following fee:  

Physician (1 day) - $200
Physician (both days) - $350
Nurses, allied health professionals and trainees (1 day) - $150
Nurses, allied health professionals and trainees (both days) - $250

I will be paying my fees:  

online through PayPal