Registration & Program Guide - The Canadian Pain Society

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34TH ANNUAL SCIENTIFIC MEETING REGISTRATION FORM, 2013 34th ANNUAL SCIENTIFIC MEETING MAY 8th - 10th, 2013 THANK YOU FOR REGISTERING FOR THE 2013 CONFERENCE. PLEASE COMPLETE BOTH PAGES OF THE REGISTRATION FORM IN FULL AND READ AND ACCEPT THE CANCELLATION CLAUSE. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE OFFICE AT OFFICE@CANADIANPAINSOCIETY.CA OR 905-404-9545. 1. CANCELLATION CLAUSE: Cancellations received prior to FRIDAY APRIL 5, 2013 are subject to a $60.00 administration fee. After Friday April 5th there will be no refunds, however delegate substitution can be made until FRIDAY APRIL 19, 2013 with no substitution fee. After FRIDAY APRIL 19th a $60.00 delegate substitution fee applies. I HAVE READ AND ACCEPTED THE CANCELLATION CLAUSE: 2. REGISTRATION TWO WAYS: Online: (Credit card payments) http://www.canadianpainsociety.ca/en/conference_2013/ Mail: (Cheque payments) 1143 Wentworth Street W. Suite 202, Oshawa, ON L1J 8P7 3. MEMBERSHIP If you are a current CPS member, please choose the member rates below. If you are not a member, please choose the non-member rates. If you want to join now and take advantage of the member rates, check the appropriate box under this section. I am a current member I am not a member and will choose the non-member rates I will be joining now 4. DELEGATE REGISTRATION INFORMATION: One form per person. Photocopies are accepted. Please circle one: Dr. Professor Mr. Mrs. Ms. Other __________ Professional Designation _________ Highest Academic Degree__________ First Name: _________________________________________________________ Last Name: _______________________________________________________ Organization or Affiliation: _______________________________________________________________________________________________________________ Address: Home or Office ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ City: ________________________________Province: ____________________ Postal Code:_____________________ Country: __________________________ Email: __________________________________________________________________________________________________________________________________ Tel:_________________________________________________________________Fax:________________________________________________________________ GUEST NAME: REQUIRED IF PURCHASING A DINNER TICKET FOR A GUEST Guest First Name: __________________________________________________ Guest Last Name: __________________________________________________ Dietary, Allergies or other Special Considerations: ________________________________________________________________________________________ If requesting Kosher or other special meals which must be brought in from outside the facility, there will be a ‘upcharge’ to cover additional cost including the cost of delivery. 5. CONCURRENT SESSIONS: Concurrent sessions must be chosen with registration. If you do not choose your sessions, there is no guarantee that your choice will be available onsite due to room capacities. Only one session per time slot will be accepted – Circle your choice WEDNESDAY MAY 8th 10:30 AM - 101 102 103 1:30 PM - 104 105 106 3:30 PM - 107 108 109 THURSDAY MAY 9th 11:00 AM - 201 202 203 1:15 PM - 204 205 206 3:45 PM - 207 208 209 FRIDAY MAY 10th 11:15 AM - 301 302 303 1:15 PM - 304 305 306 6. FAMILY PRACTICE PAIN EDUCATION GROUP MEETING AND LUNCHEON — Open to Primary Care Practitioners Only Available to the first 25 people who register for this luncheon meeting. THURSDAY MAY 9, 2013 - 12:00 pm - 1:15 pm I would like to attend: A confirmation will be sent to you for this event. If the event is full, you will be notified. 7. NURSING ISSUES SIG LUNCHEON AND ANNUAL GENERAL MEETING THURSDAY MAY 9, 2013 - 12:00 pm - 1:15 pm If you are a Nursing Issues SIG member and will be attending the AGM and luncheon, please indicate here 8. DINNER AND AWARDS EVENING ($75.00 BEFORE APRIL 19th, AND $95.00 from APRIL 20th TO MAY 8th ) Thursday May 9, 2013 -7:30 pm—11:00 pm. You must purchase a ticket for this dinner event. Choose the appropriate box on the registration form for payment. Yes, I will be attending Yes, I will be purchasing a guest ticket(s) for this event: Name is above, under Guest Name. 34TH ANNUAL SCIENTIFIC MEETING Program and Registration Guide 2013 PAGE 30
34TH ANNUAL SCIENTIFIC MEETING REGISTRATION FORM, 2013 - PAGE 2 34th ANNUAL SCIENTIFIC MEETING MAY 8th - 10th, 2013 REGISTRATION FORM CONTINUED 9. PLEASE PROVIDE YOUR NAME ON THIS PAGE TO ENSURE YOUR REGISTRATION FORM REMAINS TOGETHER: First Name: _________________________________________________________ Last Name: _______________________________________________________ 10. CHOOSING REGISTRATION FEES: CIRCLE YOUR CHOICES AND TOTAL CPS Conference Registration fees are categorized by member fees, non-member fees and trainee fees. Member Early Bird: Choose early bird fees if registering before and including March 11th (regular members only). Members: Choose regular fees if registering between March 12th and April 19th, inclusive. Non-members or Trainee: Choose regular fees to April 19th. Onsite Fees: Choose onsite fees if registering from April 20th, or any date after and throughout the Conference. If registering for the Ontario College of Family Physician’s Course – Pain & Addiction – A Primer for the Family Physician, there are no discounted or early bird fees. These fees are being collected for the College through our registration process. Please include this fee in your total. Limited to the first 30 registrants. OCFP PAIN & ADDICTION COURSE MAY 7TH – 8:30 AM – 5:00 PM CONFERENCE MEMBER FEES THREE-DAY CONFERENCE PACKAGE – MAY 8th TO MAY 10th ANY TWO-DAY CONFERENCE PACKAGE – MAY 8th, MAY 9th, MAY 10th (circle two days) ONE DAY FEE–EITHER MAY 8th, MAY 9th OR MAY 10th (circle one day) EARLY BIRD FEE TO MARCH 11th $690.00 $465.00 $360.00 FEE TO APRIL 19th $450.00 REGULAR FEE MARCH 12th – APRIL 19th $760.00 $495.00 $390.00 ONSITE FEE FROM APRIL 20th $525.00 ONSITE FEE FROM APRIL 20th $960.00 $595.00 $450.00 CONFERENCE NON-MEMBER FEES THREE-DAY CONFERENCE PACKAGE – MAY 8th TO MAY 10th N/A REGULAR FEE TO APRIL 19th $820.00 ONSITE FEE FROM APRIL 20th $1,025.00 ANY TWO-DAY CONFERENCE PACKAGE – MAY 8th, MAY 9th, MAY 10th (circle two days) N/A $540.00 $660.00 ONE DAY FEE–EITHER MAY 8th, MAY 9th OR MAY 10th (circle one day) N/A $475.00 $540.00 CONFERENCE TRAINEE FEES THREE-DAY CONFERENCE PACKAGE – MAY 8th TO MAY 10th N/A REGULAR FEE TO APRIL 19th $200.00 ONSITE FEE FROM APRIL 20th $245.00 ANY TWO-DAY CONFERENCE PACKAGE – MAY 8th, MAY 9th, MAY 10th (circle two days) N/A $170.00 $195.00 ONE DAY FEE–EITHER MAY 8th, MAY 9th OR MAY 10th (circle one day) N/A $150.00 $215.00 11. FEE TOTALS: CPS Conference Registration fees as selected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OCFP Pain & Addiction Course Registration Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dinner & Awards Evening Ticket, before April 19th _______# tickets x $75.00 . . . . . . . . . . . . . . . . . . Dinner & Awards Evening Ticket, from April 20th to May 8th _______# tickets x $95.00 . . . . . . . . . . Child Fee __________ # of children x $40.00 (Breakfasts, Breaks and Lunches only) . . . . . . . . . . . . . If you are not a member - join now to get the member rates! CPS Membership Fee, Regular, $195.00 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CPS Membership Fee, Trainee, $45.00 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUB TOTAL OF ALL FEES: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . HST APPLICABLE ON CPS CONFERENCE FEES, TICKETS AND MEMBERSHIP, 13% (#130451156RT0001) HST APPLICABLE ON PAIN & ADDICTION COURSE, 13% (#133457945RT0001). . . . . . . . . . . . . . . . . . TOTAL FEES: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ 12. PAYMENT A. ONLINE: (Credit card payments) http://www.canadianpainsociety.ca/en/conference_2013/ B. By Mail: With cheque payable to: Canadian Pain Society, 1143 Wentworth Street West, Suite 202, Oshawa, ON L1J 8P7 13. QUESTIONS? Georgina Smith, Registration Manager—georgina@canadianpainsociety.ca; georgina@eventsinsync.com; georgina@gdsmithevents.com; T: 905-404-9545 34TH ANNUAL SCIENTIFIC MEETING Program and Registration Guide 2013 PAGE 31
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