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5th rendez-vous Santé en français

« Health, networks, a movement : Bridging »

June 23-25 2010
Charlottetown, Prince Edward Island

REGISTRATION FORM

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checked>J'accepte ces conditions.

* Required field

PERSONAL INFORMATION
Salutation :	checked>Sir checked>Madam
First name:*
Last name:*
Function:*
Business / Organization:*
Address:*


City:*
Province / Territory:*
Postal code:*
Telephone:*
Fax:
Email:*
Partner type:*	#Inscription.client#
Yes No	To encourage networking, I accept to release the information provided above, and allow it to be included in participants' conference packages.

Participation

checked> I would like to register for the 5^th Rendez-vous Santé en français (June 23-25, 2010)

checked> I am a first-time participant of Rendez-vous Santé en français

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	#event.periode1# Expiré	#event.periode2# Expiré	#event.periode3# Expiré	#event.periode4# Expiré
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* Registration fees of $350 include: conferences, receptions, breakfasts (Wednesday, Thursday and Friday), reception (Wednesday), banquet (Thursday evening), breaks, and documents.

** Registration deadline for the 5^th Rendez-vous Santé en français is May 28, 2010.
There will be no refunds after May 28, 2010.

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	#event.item9#	X #event.prixunite9# $	$
	#event.item10#	X #event.prixunite10# $	$
MONTANT ADDITIONNEL À PAYER :			$
MONTANT TOTAL À PAYER :			$
Prénom et nom des invité(e)s
1. 2. 3. 4.

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MEALS
A banquet will be held on Thursday, June 24, 2010.
* Please indicate your choice of meal:
checked> Chicken
checked> Fish
checked> Vegetarian
checked> I will not be attending the banquet
**Participants who want an extra ticket for the banquet on Thursday, June 24 at a cost of $ 80/person. Fill in the application form to the tab Extra Banquet Ticket*.

RESTRICTIONS
checked> Dietary restrictions	Please specify:
checked> Allergies	Please specify:
checked> Mobility impairment
Specific needs during your stay (intended for people with special needs) #Inscription.besoins1#

Personne qui vous inspire
Veuillez indiquer le nom d'une personne qui vous inspire et vous garde accroché à la santé en français ?

METHOD OF PAYMENT *
checked> Credit card/Paypal
checked> Personal cheque (made payable to La Société Santé en français) Please print your completed registration form and mail it, along with your $350 registration fee, to the attention of Diane Dallaire, person in charge of registrations. Send it to: Dynapro 44 Jeanne-D'arc Street Gatineau, QC, J8Y 2H2

Comment
Your Comment #Inscription.commentaires#

RÉSERVÉ À L'ADMINISTRATION
Montant facturé	Montant #Inscription.grandtotal#	Date de la demande
Paiement reçu checked>Oui checked>Non	Montant	Date du paiement
Remboursement déplacement checked>Oui checked>Non	Montant	Date de confirmation
Personne qui traite la demande	NIP " size="15">	Modification
Langue de service désiré : Français checked>Oui checked>Anglais Statut de l'inscription checked>En cours checked>Incomplet checked>Confirmé checked>Refusé checked>Accréditation reçue checked>Afficher cette note d'information dans le compte du participant #Inscription.notes#

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NOTE 1 : You will receive an email confirming the payment transaction

NOTE 2 : Registration fees are to be paid before your arrival.

For more information, or for inquiries on your registration form, please contact Denis Gélineau at 1-819-663-7533 or at finances@gelineau.ca

For more information, or for inquiries on Workshops and partnerships, please contact Benoit Hubert at: 1-613- 241-2251, extension 237 or at rendezvous@santefrancais.ca

Workshops We are currently finalizing the program content for the 5^th Rendez-vous. At the end of May, registered participants will receive an invitation to sign up for the different workshops offered. Workshop registration will be available online from May 31^st to June 6^th inclusively, on a &##8220;first come, first served&##8221 basis as space is limited. Do not forget to provide us with an email address so we can inform you when workshop registration opens.