2019 Pediatrics Courses

A. Identification

Salutation:

First Name:*

Last Name:*

Title/Position:

Department/Division:

Organization:

Address:*

City:*

Province/State:*

Postal/ZIP Code:*

Country:*

Telephone:*

Mobile:

Fax:

E-mail:*

Where did you hear about these courses?

Resident MD Nurse Other

Medical Speciality:

Professional License Number

Please check here if you do not want your email address to appear on the list of participants which may be distributed to participants.

B. Special Needs

Please indicate any special needs (dietary, wheelchair access, etc.):

C. Workshop Preferences

ANNUAL SPECIALTY DAY: Pediatric Respirology

February 13, 2019

SESSIONS I & II

Please rank the workshops in order of preference (1 to 3). You will be assigned to 2 workshops on a first-come, first-reserved basis.

Choice:	Workshop Name:
	Dyspnea
	Recurrent Pneumonia
	Excessive Daytime Sleepiness

SESSIONS III & IV

Please rank the workshops in order of preference (1 to 3). You will be assigned to 2 workshops on a first-come, first-reserved basis.

Choice:	Workshop Name:
	Pulmonary Function Tests Interpretation
	Functional Respiratory Problems
	Asthma

PRACTICAL PROBLEMS IN PEDIATRICS

February 14, 2019

Please rank the workshops in order of preference (1 to 6). You will be assigned to 3 workshops on a first-come, first-reserved basis.

Choice:	Workshop Name:
	A Stitch in Time – Suturing 101 for the Office Setting CLOSED
	Baby Steps – When to Worry About the Lower Limbs
	Pills Are Passé – Are IUDs the Future?
	Clinical Exam Pearls in Child Protection
	A Picture Is Worth a Thousand Words – Dermatology Potpourri
	To Echo or Not to Echo? – That Is the Question.

D. Registration Fees

For Physicians
	Pediatric Respirology Feb. 13, 2019	Practical Problems in Pediatrics Feb. 14-15, 2019	Both Courses Feb. 13, 14, 15, 2019
Early Bird: Before Dec. 14, 2018	$360	$595	$815
Regular: After Dec. 14, 2018	$395	$655	$900

For Nurses or Residents
	Pediatric Respirology Feb. 13, 2019	Practical Problems in Pediatrics Feb. 14-15, 2019	Both Courses Feb. 13, 14, 15, 2019
Early Bird: Before Dec. 14, 2018	$285	$385	$515
Regular: After Dec. 14, 2018	$310	$415	$545

For Invited Speakers
Click if you are an invited speaker		$0

On-site registration*
....................	Pediatric Respirology Feb. 13, 2019	Practical Problems in Pediatrics Feb. 14-15, 2019	Both Courses Feb. 13, 14, 15, 2019
After Feb. 1, 2019	$420	$715	$999
A one-day registration for the Practical Problems in Pediatrics Course is $395. After Feb 1, 2019 one-day registration is $420.00. Early Bird is before December 14, 2018. After December 14, 2018, prices revert to Regular. *After February 1, 2019, registration will be done on site. On-site registrants will be assigned workshops on the basis of availability.

E. Meet the Expert

I wish to attend the following Meet the Expert lunchtime session(s) (cost $40 per session; space is limited; first-come, first served):

Thursday, Feb. 14, 2019	Gastroenterology ... OR ... Adolescent Medicine/Gynecology Clear Entry	$
Friday, Feb. 15, 2019	Infectious Diseases ... OR ... Child Psychiatry CLOSED Clear Entry	$

Meet the Expert Fees: $

Cancellation Policy

Full refunds, less an administrative fee of $50.00, will be made for written cancellations received by January 11, 2019. After January 11, 2019, only 50% will be refunded, and no refunds will be issued for cancellations received after February 1, 2019.

I have read and acknowledge the cancellation policy.

F. Method of Payment

Total Amount (Registration Fee + Meet the Expert): $

	Online Credit Card Payment (VISA, Mastercard, Discover, American Express, Diners Club, Carte Blanche, JCB and Visa Debit)
	Certified Cheque/Money Order/Bank Draft (Please make payable in Canadian funds to "O'Donoughue & Associates Event Management Re : Pediatric Courses")
	Credit Card Payment by Fax

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Registration Form