Conference Registration

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Manager's Name

First Name

Last Name

Manager's Phone

(###)

###

####

Will you be attending the Meet and Greet at Western Memorial Hospital? *

Thursday May 29, 2025 (7:00-8:30pm)

Yes

No

Will you be attending the Western Memorial Hospital Tour? *

Thursday May 29, 2025 (6:00pm)

Yes

No

Will you be attending the lunchtime MAID Presentation by Dr. Amy Pieroway? *

Yes

No

Please choose one of the following concurrent sessions. *

Seating may be limited depending on numbers interested in each session.

Session A: Case Discussion on Pain Control and Dealing with Nausea (clinical stream). Dr. Kate Lafferty

Session B: Preparations for Death (Social Work and Spiritual Stream). Sandra Lush and Alison Judd

Would you like to purchase a bagged lunch ($25.00)?

If yes, you will be prompted to select from three options.

Yes

No, i will bring my own lunch.

Do you have any accessibility requirements for which you need accommodation?

If yes, you will be contacted to organize accommodation.

Yes

No

Do you have any food allergies or restrictions that we should be aware of?

Yes

No