State of the Union 2010 Survey

Registration for the 2010 State of the Union is now open!!

Simply fill out the form below to provide us with all of the information we need to process your registration.
If you have any questions, please do not hesitate to contact us.

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1. Name

Name First Name:
Last Name:

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2. Affiliation

Affiliation Position:
Organization:

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3. Address

Address Street:
City:
Province:
Postal Code:

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4. Contact Information

Contact Information Telephone #:
Email:

*
5. Please indicate which session(s) you will attend:

Please indicate which session(s) you will attend: Morning (Conference)

Afternoon (Workshop)

6. If you are attending our afternoon workshop(s), please indicate which of the following you hope to attend:

If you are attending our afternoon workshop(s), please indicate which of the following you hope to attend: IT/IM: e-intake/referral, health records and centralized databank of services

Single Point of Access/Entry

Physician Engagement in Hospice Palliative Care (Dr. Sandy Buchman, Regional Primary Care Lead, Toronto Regional Cancer Program)

Most Responsible Person/Agency ((Dr. Raymond Berry, Medical Director, Long-Term Care, Toronto Rehabilitation Institute)

Education & Linkages with Emergency Departments (Ms. Susan Blacker, Director Cancer Services Planning and Performance, St. Michael's Hospital)

Education & Linkages with Community Care Access Centers

No Preference

7. Exhibit space will be made available to our network members for display of resource materials and/or handouts. Please indicate if you would like to have materials displayed.

Exhibit space will be made available to our network members for display of resource materials and/or handouts. Please indicate if you would like to have materials displayed. Yes

8. If you answered yes to the previous question, please indicate which materials you wish to bring:

	Yes	No
Brochures	*If you answered yes to the previous question, please indicate which materials you wish to bring: Brochures Yes	Brochures No
Pamphlets	Pamphlets Yes	Pamphlets No
Handouts	Handouts Yes	Handouts No
Research Posters	Research Posters Yes	Research Posters No

9. Would you like to be placed on our distribution newsletter list?

Would you like to be placed on our distribution newsletter list? Yes

State of the Union 2010
Exit this survey

1. Registration

*
1. Name

*
2. Affiliation

*
3. Address

*
4. Contact Information

*
5. Please indicate which session(s) you will attend:

6. If you are attending our afternoon workshop(s), please indicate which of the following you hope to attend:

7. Exhibit space will be made available to our network members for display of resource materials and/or handouts. Please indicate if you would like to have materials displayed.

8. If you answered yes to the previous question, please indicate which materials you wish to bring:

9. Would you like to be placed on our distribution newsletter list?

State of the Union 2010Exit this survey

1. Registration

*1. Name

*2. Affiliation

*3. Address

*4. Contact Information

*5. Please indicate which session(s) you will attend:

6. If you are attending our afternoon workshop(s), please indicate which of the following you hope to attend:

7. Exhibit space will be made available to our network members for display of resource materials and/or handouts. Please indicate if you would like to have materials displayed.

8. If you answered yes to the previous question, please indicate which materials you wish to bring:

9. Would you like to be placed on our distribution newsletter list?

State of the Union 2010
Exit this survey

*
1. Name

*
2. Affiliation

*
3. Address

*
4. Contact Information

*
5. Please indicate which session(s) you will attend: