REGISTRATION FORM Registration via fax to:
Critical Care Canada Forum Toll-free - 1-888-527-2905
November 7 – 10, 2010 (credit card payments only; for cheque
Sheraton Centre, Toronto payment please see mailing address on reverse)
GENERAL INFORMATION (please print neatly) O RN
O Dr. O Mr. O Mrs. O Ms. O Fellow/Resident
______________________________________ ______________________________________ O Other (please specify) ________________________
First Name Last Name
___________________________ ___________________________ ___________________________________________________________
Province/State Postal / Zip Code Country
____________________________________ ___________________ ___________________________________________________________
Work Phone Ext. Mobile Number
Are you the presenting author of a submitted abstract at this meeting? O Yes O No
Registration must be accompanied by payment. Registration fees include: HST (HST# 868 718 149 RT0001), forum materials, lunches and
refreshment breaks. Full conference registration permits delegates to attend any of the sessions detailed on the program unless
separate registration is indicated. Fees are in Canadian dollars (USD at current rate).
Early Reg Regular Reg
Physicians (until Sep 27, 10) (after Sep 27, 10)
(PF) Full Conference O $795.00 O $895.00
(P) Single Day – specify: O Mon O Tues O Wed O $425.00 O $555.00
Residents/Fellows (Letter from Program Director is required with your registration, please fax to 519-263-2936)
RTs, RNs, Pharmacists, Other
(RF) Full Conference O $395.00 O $495.00
(R) Single Day – specify: O Mon O Tues O Wed O $245.00 O $345.00
Students in Canadian Programs
(Respiratory Therapy, Nursing, Pharmacy or Medical Students; confirmation of current enrolment please fax to 519-263-2936
(S) Full Conference O $190.00 O $190.00
Scientific Abstract Presenters: The presenting author of an accepted scientific abstract will receive a full credit, applied to
registration. Scientific abstract submission is required with your registration.
Registration of a group of 10 or more non-physicians (RTs, RNs, pharmacists etc.) who pay full conference fee will receive $500 after the
conference towards an educational fund. For full details or to obtain a group registration form, please contact The Bayley Group at
1.888.527.3434 or email firstname.lastname@example.org .
Monday, November 8, 2010 - 5:00pm – 8:00pm
The Critical Care Canada Forum invites all delegates to attend this unique evening at a fabulous Toronto location.
Please indicate if you will be attending: O YES O NO
Bedside Ultrasound in the ICU with Dr. Yanick Beaulieu at Mitchener Institute
Sunday, November 7, 2010
As a world premiere, the hands-on portion of the course will allow the participants to practice scanning of acute cardiac
pathologies such as LV dysfunction, RV dysfunction and tamponade.
Cost is $795.00 US – To register please visit: https://www.iccuimaging.ca/secure.php#/training/78/home/
For more information and/or to register online for the Forum, please go to www.criticalcarecanada.com. For abstract
submissions, please visit http://cccf2010.abstractcentral.com or contact The Bayley Group at 1.888.527.3434.
Would you like to make a donation to the Canadian Intensive Care Foundation (CICF)?
O $20.00 O $50.00 O Other $____________
Payment (in Canadian dollars) must accompany registration.
Payment method: O Cheque O VISA O MasterCard O AmEx
Registration Fee: $ ________________
Card # ________________________________________________________
CICF Donation: $ ________________
Exp (mm/yy) _______/________ CVV Code ___________________
CCCS Member Discount*: $ ________________
Name of Cardholder ___________________________________________
Total amount enclosed $ ________________
* Current CCCS members receive a $75 discount on their registration.
Primary Abstract Authors: A full credit will be applied to registrations for presenting authors.
I hereby authorize the Critical Care Canada Forum to debit my credit card account for the total amount indicated above.
Note: Credit card charges will appear as Critical Care Canada Forum.
The CCCF is pleased to offer all registrants of the 2010 conference a complimentary, online subscription to Critical Care. A valid
email address is required in order to provide the subscription. Please check here if you do not wish to receive it: O No thanks
An administration fee of $50 applies to all cancellations before October 19, 2010. NO REFUND after October 19, 2010.
FAX the registration form (credit card payments only) to: 1-519-263-2936 / 1-888-527-2905
MAIL the registration form (credit card or cheques, made payable to: Critical Care Canada Forum, to:
Critical Care Canada Forum
c/o The Bayley Group
PO Box 39 - Hensall, ON
N0M 1X0 - CANADA