REGISTRATION FORM

REGISTRATION FORM Registration via fax to: 1-519-263-2936 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) O MD GENERAL INFORMATION (please print neatly) O RN O RT O Pharmacist O Dr. O Mr. O Mrs. O Ms. O Fellow/Resident O Student ______________________________________ ______________________________________ O Other (please specify) ________________________ First Name Last Name _________________________________________________________ ___________________________________________________________ Title Department ___________________________________________________________________________________________________________________________ Institution ___________________________________________________________ ___________________________________________________________ Address City ___________________________ ___________________________ ___________________________________________________________ Province/State Postal / Zip Code Country ____________________________________ ___________________ ___________________________________________________________ Work Phone Ext. Mobile Number ___________________________________________________________ Email Are you the presenting author of a submitted abstract at this meeting? O Yes O No REGISTRATION INFORMATION 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. Group Incentive: 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 registration@criticalcarecanada.com . -1-

WELCOME RECEPTION 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 INFORMATION 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 $ ________________ Signature ______________________________________________________ * 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 Refund/Cancellation Policy: 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 -2-

REGISTRATION FORM

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