REGISTRATION
PLEASE PRINT OUT AND SEND BY MAIL OR FAX

Name_________________________________________Title ________
Address___________________________________________________
City_______________________________________________________
Province/State___________________Postal/Zip Code______________
Telephone_______________________Fax________________________

Registration


Anaesthetic Practice 1998		 After Nov 6th
$CDN $US $CDN $US
Specialist [ ] FP/GP Anaesthetist [ ] $325 $225 $375 $275
One Day Registration [ ] $175 $125 $200 $150
Resident*/Fellow*/Paramedical* [ ]
$50 per day
I cannot attend. Please send syllabus. Enclosed is: $ 50 $35
*Letter from Department Head required for reduced-fee registration
AP Workshop Registration
Fibreoptic Intubation [ ] $50 $35

TOTAL

 _______ $ CDN or US

PRACTICAL WORKSHOPS/BREAK OUT SESSIONS

For each small group session/workshop you are interested in attending, indicate your session choice depending on time and date in order of preference. These sessions run concurrently with lectures (Refer to program). In order to keep group sizes reasonable, limits will be set on each session and registration is on a first come basis. On site registration cannot be guaranteed for these sessions.

In the boxes below please indicate your choice in order of preference (1 for 1st, 2 for 2nd choice, etc.).

  Friday PM Saturday PM
1330-1500 1530-1700  
Fibreoptic Intubation Workshop (FOB) FOB

Session I

 FOB

Session II
Problem

Based

Learning

Acute Pain

Session I

 Acute Pain

Session II
  1415-1530 1545-1700
Trauma
Anaesthesia

Session I

 Trauma
Anaesthesia

Session II
Regional

Anaesthesia

Session I

 Regional

Anaesthesia

Session II

A $50 administrative fee will be retained for written cancellation received prior to November 6, 1998. No refunds will be available after November 6, 1998.

Payment:
Please charge my [ ] VISA [ ] MASTERCARD #.___________________________________
Expiration Date ___________ Name on card:______________________
I authorize Anaesthetic Practice to charge my account for the registration fee(s) and indicated optional workshops TOTAL $____________CDN or US

Signature________________________________________________________

OR

Please make Cheques/Money Order payable to;
"Anaesthetic Practice 1998"

*No Refunds will be issued for currency discrepancies.*

Mail to:

FAX to: