Canadian Critical Care Review

Online Registration

May 28-29, 2012

Section A - Delegate Information
If you experience any technical difficulties when using this form or if you have registration questions, please contact Canadian Critical Care Review Program at: brunslo@criticalcarereview.ca.

Email Address:
Title:
First Name:
Last Name:
Program Director:
Department:
Institution:
Address Line 1:
Address Line 2:
City/Town/Village:
State/Province:	(Canada or U.S.A only) - If "Other" then please specify -
Zip/Postal Code:
Country:
Phone Number:	Ext:
Fax Number:

Please indicate if you have any dietary restrictions, requirements or allergies:

Special Needs:

Additional Comments:

I have completed or will be completing my training in 2012: Yes No

Section B – Delegate Registration
Registration fees include: admission and online meeting archive recording for all sessions, breakfasts, lunches and nutrition breaks indicated in the program.

	Early Bird Pricing Before April 7, 2012	Regular Price After April 7, 2012
Residents/Fellows or International Medical Graduates Registered in a Canadian Program.	$300.00	$400.00
Physicians and Others who are members of the Canadian Critical Care Society.	$650.00	$750.00
Physicians and Others	$750.00	$850.00

Hotel Accommodation and Travel Arrangements
Participants are responsible for their own travel and accommodation arrangements. A group room rate of $119 CAD per room (single/double occupancy) per night (plus applicable taxes) is being offered to participants. Rooms at the conference rate are available until the reserved block of rooms is filled or March 16, 2012, whichever occurs first. It is therefore recommended that participants requiring accommodations book as soon as possible. You must indicate that you are with the Canadian Critical Care Review Program to receive this group rate.

Please contact the hotel directly at:

Delta Meadowvale Conference Centre
6750 Mississauga Rd.
Mississauga, ON, L5N 2L3

Tel: 905-821-1981
Fax: 905-542-4036
www.deltahotels.com

Section C – Payment Information
Please verify all the information is correct. By submitting your payment your credit card statement will show this transaction as Canadian Critical Care Review Program.

Cancellation Policy
All cancellations must be received in writing no later than May 14, 2012 for a full refund, less an administrative fee of $50.00. No refunds will be issued after this date.

I acknowledge that I have read and accept the conditions of this policy

Press Submit to complete your registration.

If you experience any technical difficulties when using this form or if you have registration questions, please contact Canadian Critical Care Review Program at: brunslo@criticalcarereview.ca

Already Registered?

If you have already registered but have not yet paid you can pay your registration fee here.

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