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Salutation

First name

Last name

Organization

Please select the Ontario Health Region you serve:
Please selecta. North-East Regionb. North-West Regionc. East Regiond. Central Regione. Toronto Regionf. West Region

For more information of where your region falls, please visit Ontario Health Regions – Ontario Health

Position/Job Title

Practice location
Please selectCommunityInpatientOutpatientEmergency DepartmentLong-term Care Facility

Email

Phone number with extension

Please select if you work in any of the following areas of Specialized Geriatric Services
Please selectGeriatric Assessment Outreach TeamGeriatric Day HospitalGeriatric Emergency MedicineGeriatric InpatientGeriatric Consultation TeamGeriatric Rehabilitation UnitGeriatric PsychiatryNot Applicable

Please list 3 things you are hoping to take away from this course:

Item 1
Item 2
Item 3

Other comments

Fee Type
Select Fee TypeRegistration fee - $200

Payment Options
Please selectCredit CardOther