REGISTRATION FORM

Thank you for registering for the

27th Annual Paediatric Day Conference

October 17, 2018

Early Bird Fee          

$25.00 - Students/Residents

$50.00 - Nurses

$75.00 - Physicians

 

Late Registration (after Sept. 21st)

$40.00 - Students/Residents

$65.00 - Nurses

$90.00 - Physicians


Email
Title
First Name
Last Name
Position/Designation
Mailing Address
City
Country
Province
Postal Code
Daytime Phone Number

Payment Information:

*Contribution Amount = Registration Fee

Frequency:
Contribution Amount:
CAD

Cardholder Name:
Credit Card #:
Security Code (CVV2):
Card Type:
Expiry:
MM/YY

Additional Attendee Information
Please provide us with the full names, titles and email addresses for any additional attendees you are registering.
 



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Stratford General Hospital Foundation
46 General Hospital Drive
Stratford, ON N5A 2Y6
Canada