Trillium Research Day  - Primary Health Care Research Day

 

REGISTRATION


Primary Health Care Research Day- Trillium 2017
Sheraton Centre Hotel, 123 Queen Street West
Mezzanine Level - Willow Centre & Willow East
Toronto
Wednesday, May 31st, 2017


Registration DEADLINE: Tuesday, May 30, 2017
Payment deadline: Tuesday, May 31, 2017
Please note: We recognize that payment by cheque may be delayed past the Registration deadline of May 31, 2017.
We will follow up if payment is not received by June 9th.

REGISTRANT INFORMATION:
Title:
Surname:
First Name:
Status:

Researcher
Clinician
Administrator
Graduate Student Resident
      (For presenting Graduate Students/ Residents: Limited travel
       grants available based on geographical representation.
       If lead and co-presenter are both presenting they will share one travel grant.)
Patient / Community Member
       (Limited travel grants based on geographical representation)
Other, please specify  

Institution/Affiliation/Company:
Department:
Address:
City:
Province:
Postal Code:
Phone:
Fax:
Email: (mandatory)
Alternate Contact Name:
Alternate Contact Email:
Alternate Contact Phone #:
   
CONFERENCE DETAILS:
Main Discipline:
Please specify discipline:
Please select a Workshop: ( 2:40 pm - 4:00 pm )
Workshop 1: - In Room Linden
Primary Care measures at the sub-region level
Facilitated by Dr. Richard H. Glazier, ICES and Paul Huras, SE LHIN
Workshop 2:  - In Room Cedar
Patient Building Patient Engagement in your Research Proposal – The role of the patient partner across the research cycle
Undecided
Did you submit an abstract?
Yes, I have already submitted an abstract.
I will be sending in my abstract.
No I am NOT submitting an abstract
Undecided
   

Please advise if you have any food allergies:

REGISTRATION FEES:


Registration Fee:
Please select appropriate fee:

  Presenting Non-Presenting
Attendee $84.75 $101.70
Resident/Student Free if Presenting
 ** Limited travel grants are available
$56.50
Patient
/ Community Member
Free if Presenting
 ** Limited travel grants are available
$56.50
** Please note: Limited travel grants will be made available by geographical regions for presenting student, resident, patient and community members.  If co-presenting the grant will be shared with your co-presenter.  If selected you will be notified by email.

I will pay registration costs by:
Cheque (payable to "The University of Western Ontario")
On-line Credit Card Payment (Visa or Master Card) -- secure link at Western.
       
 (If you choose on-line Credit Card, on next screen you wil be asked for the credit card details.)

Verification Submission Code:
Please enter the text you see in the image. Make sure you enter it exactly as you see it(upper and lower case). This is required to prevent us from getting spam submissions. Then press the Submit button to send your form. Thank you.