Online Registration for March 10-17, 2007 International Conference

You may complete online registration below, or provide registration information while booking cabins with Thomas Cook. To submit online registration, complete form and then click "Submit Form" button at bottom of page.

If you submit online registration below, you will be contacted for completion of cabin bookings.

Fields marked with * must be filled before online form can be submitted.

Please enter a valid e-mail address where you can be contacted (if you do not have
e-mail, you may still use this form by entering "register@psychiatryreviewcourse.com"
in the field below - we will then contact you with the other contact information you provide.
Please ensure accuracy of contact information, or we will not be able to reach you.)

E-mail address: *    

Registrant Name (as it appears in passport): *               
             
Professional Designation: *   
 - select from list below -
 Family Physician
 Psychiatrist
 Other physician (please specify below)
 Psychologist
 Social Worker
 Nurse
 Other (please specify below)
             
             If "Other", please specifiy:   
   (Please note, this is solely for the purposes of identifying the demographics
   of conference attendees.  You may indicate at time of booking with Thomas Cook
  whether you wish travel documents to bear the designation of "Dr.", "Ms.", "Mr.", etc.)

Nationality (as on passport):   

Date of Birth: (yyyy-mm-dd):   
  
Address:  *                 City:                    
             
Province/State:            Country:  
             
Postal/Zip Code: 
             
Phone: *  

Fax:             
             
How did you hear about the conference?: *  

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TRAVELLING COMPANIONS (names as they appear in passports):

PLEASE NOTE: If nationality for any travelling companions is DIFFERENT from that
of registrant, please indicate this in the "Comments" field at bottom, otherwise it will be 
assumed all travellers are the same nationality as registrant..

Companion 1 - Name:           DOB:  

Companion 2 - Name:           DOB:  

Companion 3 - Name:           DOB:  
   [if additional companions, please write in the "comments" field at bottom]

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Cabin preference - first choice:      - select from list below -Inner stateroom (cat 11)Oceanview stateroom (cat 9)Balcony stateroom (cat 6)Larger family cabin (cat 4)

Cabin preference - second choice:  - select from list below -Inner stateroom (cat 11)Oceanview stateroom (cat 9)Balcony stateroom (cat 6)Larger family cabin (cat 4)

Please indicate dinner seating preference:  
 - select early or late -
 Early seating (approx 6:15 pm)
 Late seating (approx 8:30 pm)


Medical and/or Travel Insurance (recommended):  
 Accepted
 Declined


Flights required:  - select Yes or No -Yes No 

Transfers to/from port required:  - select Yes or No -Yes No 

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Base Registration Fee : *  Regular Registration: $695 Cdn till Sept 5 Resident/Spousal Registration: $475 Cdn 
                                                           (in Canadian dollars; no GST)     
       

Are you interested in the optional "CME To Go" Program?:  Yes, I would like to participate: + $60No, I am not interested: $0Maybe, please tell me more about it
                    [if you need more information on the program, select "Maybe", you may enroll for
                     this program after regular registration complete if you chose]

Check box if eligible for "Introduce a Colleague" $75 deduction:                      
             Name of colleague (if eligible for above deduction): 

Complete only if second registrant in same cabin:
             Name and professional designation of second registrant: 
                         
             Second registrant registration fee:  No Second Registrant: $0Resident/Spousal Registration: $475 Cdn Regular Registration: $715 Cdn 

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Please check to confirm you have read the "Terms and Conditions"
for the March 2007 Psychiatry Review Course conference [click to go to link]:

          Yes, I have read the Terms and Conditions for this conference *    (check box)
         
Comments:      

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Registration may be paid by credit card at time of cabin booking with Thomas Cook travel (in this case, "Thomas Cook" will appear on credit card statement for registration fee payment)

- or -

Cheque for net registration amount may be made payable to "Psychiatry Review Course"

Please note, space cannot be held until registration is complete and payment received.

Information submitted will be shared with Thomas Cook to facilitate bookings, and may also be used to keep you informed of future CME events.

             
             
             
Once you click above to submit your information, a page thanking you for submitting the form
should appear if the information was successfully submitted.  You may then use the "BACK"
button on your browser to return to this page.

Thank you for your interest in the course.  You will be contacted via e-mail shortly.

[click here to return to the Psychiatry Review Course homepage]