Full Course Registration for 6 Session Critical Care Review Sunnybrook HSC

Sunnybrook HSC (September 7 to October 19, 2019)

Registration

Question Title

* 1. FIRST NAME

Question Title

* 2. LAST NAME

Question Title

* 3. PREFERRED EMAIL (RECEIPT AND HANDOUT INFORMATION WILL BE EMAILED)

Question Title

* 4. ALTERNATE EMAIL (OPTIONAL)

Question Title

* 5. ADDRESS

Question Title

* 6. CITY

Question Title

* 7. PROVINCE

Question Title

* 8. POSTAL CODE

Question Title

* 9. HOME PHONE

Phone number

Is this a mobile device?

Question Title

* 10. MOBILE PHONE (FOR EMERGENCY NOTIFICATION)

Mobile Number

Is this the same as home phone?

Question Title

* 11. PRIMARY WORK PHONE

Phone number

Extension (if applicable)

Question Title

* 12. PRIMARY EMPLOYER

HOSPITAL OR AGENCY (PRIMARY)

UNIT (PRIMARY)

OTHER

Question Title

* 13. Amount of Payment

Early Bird Payment By September 1, 2019 ($325 includes HST)

Regular Fee After September 1, 2019 ($345 includes HST)

3 Payments Of $120 (dated by September 1, September 24 and October 10, 2019)

Question Title

* 14. Method of Payment

Electronic Bank Transfer to critcareconcepts@rogers.com (Remember to send an email with secret password when transfer is made)

Cheque or money order mailed to PO 37142, 900 Adelaide Street S, London, ONT, N6E 3T3

Question Title

* 15. I understand that handout material cannot be reproduced (in whole or in part) without permission from Critical Care Concepts. I am also aware that access to online course material is restricted to registered participants.

I agree

Question Title

* 16. Course content is provided for educational purposes only. Critical Care Concepts assumes no responsibility for the application of content in the clinical area or for the clinical decision-making of any participant.

I agree